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Weischendorff S, Rathe M, Petersen MJ, Weimann A, Enevold C, Nielsen CH, Als-Nielsen B, Nygaard U, Moser C, Müller K. Markers of intestinal mucositis to predict blood stream infections at the onset of fever during treatment for childhood acute leukemia. Leukemia 2024; 38:14-20. [PMID: 37919603 PMCID: PMC10776407 DOI: 10.1038/s41375-023-02077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Despite chemotherapy-induced intestinal mucositis being a main risk factor for blood stream infections (BSIs), no studies have investigated mucositis severity to predict BSI at fever onset during acute leukemia treatment. This study prospectively evaluated intestinal mucositis severity in 85 children with acute leukemia, representing 242 febrile episodes (122 with concurrent neutropenia) by measuring plasma levels of citrulline (reflecting enterocyte loss), regenerating islet-derived-protein 3α (REG3α, an intestinal antimicrobial peptide) and CCL20 (a mucosal immune regulatory chemokine) along with the general neutrophil chemo-attractants CXCL1 and CXCL8 at fever onset. BSI was documented in 14% of all febrile episodes and in 20% of the neutropenic febrile episodes. In age-, sex-, diagnosis- and neutrophil count-adjusted analyses, decreasing citrulline levels and increasing REG3α and CCL20 levels were independently associated with increased odds of BSI (OR = 1.6, 1.5 and 1.7 per halving/doubling, all p < 0.05). Additionally, higher CXCL1 and CXCL8 levels increased the odds of BSI (OR = 1.8 and 1.7 per doubling, all p < 0.0001). All three chemokines showed improved diagnostic accuracy compared to C-reactive protein and procalcitonin. These findings underline the importance of disrupted intestinal integrity as a main risk factor for BSI and suggest that objective markers for monitoring mucositis severity may help predicting BSI at fever onset.
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Affiliation(s)
- Sarah Weischendorff
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark.
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Allan Weimann
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Christian Enevold
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
| | - Claus H Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Huang J, Lu S, Wang J, Jiang L, Luo X, He X, Wu Y, Wang Y, Zhu X, Chen J, Tang Y, Chen K, Tian X, Shi B, Guo L, Zhu J, Sun F, Zhen Z, Zhang Y. A multicenter phase II trial of primary prophylactic PEG-rhG-CSF in pediatric patients with solid tumors and non-Hodgkin lymphoma after chemotherapy: An interim analysis. Cancer Med 2023. [PMID: 37183837 DOI: 10.1002/cam4.6079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Pegylated recombinant human granulocyte colony-stimulating factor (PEG-rhG-CSF) can be used in pediatric patients. This study assessed the safety and efficacy of PEG-rhG-CSF as a primary prophylactic drug against neutropenia after chemotherapy in pediatric patients with solid tumors or non-Hodgkin lymphoma (NHL). PATIENTS AND METHODS This phase II study (between October 2020 and March 2022) enrolled pediatric patients with solid tumors or NHL treated with high-intensity chemotherapy and with grade ≥3 myelosuppression for at least 14 days during chemotherapy. Prophylactic PEG-rhG-CSF was given at 100 μg/kg body weight (maximum total dosage of 6 mg) once 24-48 h following chemotherapy for two cycles. The primary endpoint was the incidence of PEG-rhG-CSF-related adverse events (AEs). The key secondary endpoints were the rates of grade 3/4 neutropenia and febrile neutropenia (FN). RESULTS This study included 160 pediatric patients with a median age of 6.22 (0.29, 18.00) years. Fifty-eight patients (36.25%) were diagnosed with sarcoma. AEs potentially related to PEG-rhG-CSF included bone pain (n = 32), fatigue (n = 21), pain at the injection site (n = 21), and myalgia (n = 20). The rates of grade 3/4 neutropenia and FN during treatment were 57.28% and 29.45%, respectively. CONCLUSION PEG-rhG-CSF is well tolerated and effective in pediatric patients with solid tumors or NHL. These findings should be substantiated with further trials. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04547829.
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Affiliation(s)
- Junting Huang
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Suying Lu
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Juan Wang
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Lian Jiang
- Department of Pediatrics, Hebei Tumor Hospital, Pediatric, Shijiazhuang, P. R. China
| | - Xuequn Luo
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P. R. China
| | - Xiangling He
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, P. R. China
| | - Yanpeng Wu
- Department of Pediatrics, The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou, P. R. China
| | - Yi Wang
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Xiuli Zhu
- Department of Pediatrics, Hebei Tumor Hospital, Pediatric, Shijiazhuang, P. R. China
| | - Jian Chen
- Department of Pediatrics, Hebei Tumor Hospital, Pediatric, Shijiazhuang, P. R. China
| | - Yanlai Tang
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P. R. China
| | - Keke Chen
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, P. R. China
| | - Xin Tian
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, P. R. China
| | - Boyun Shi
- Department of Pediatrics, The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou, P. R. China
| | - Lanying Guo
- Department of Pediatrics, The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou, P. R. China
| | - Jia Zhu
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Feifei Sun
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Zijun Zhen
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
| | - Yizhuo Zhang
- Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, P. R. China
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Mackie DB, Kuo D, Paul M, Elster J. Does Fever Response to Acetaminophen Predict Bloodstream Infections in Febrile Neutropenia? Cureus 2023; 15:e36712. [PMID: 37113346 PMCID: PMC10129031 DOI: 10.7759/cureus.36712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND There is a need to identify clinical parameters for early and effective risk stratification and prediction of bacterial bloodstream infections (BSIs) in patients with febrile neutropenia (FN). Acetaminophen is used widely to treat fever in FN; however, little research exists on whether fever response to acetaminophen can be used as a predictor of BSIs. OBJECTIVES Investigate the relationship between fever response to acetaminophen and bacteremia in FN. DESIGN/METHOD A retrospective review of patients (1-21 years old) presenting with FN and bacteremia at Rady Children's Hospital (2012-2018) was performed. Demographic information, presenting signs/symptoms, degree of neutropenia (absolute neutrophil count (ANC) > 500 or < 500 cells/µL), absolute monocyte count, blood culture results, temperatures one, two, and six hours after acetaminophen, and timing of antibiotic administration were examined. Patients were stratified into three malignancy categories: leukemia/lymphoma, solid tumor, and hematopoietic stem cell transplant. Patients were matched with culture-negative controls based on sex, age, malignancy category, and degree of neutropenia. RESULTS Thirty-five case-control pairs met inclusion criteria (70 presentations of FN). The mean age of the cases was 10.7 years (± 6.3) vs. 10.0 years (± 5.9) for the controls. Twenty were female (57%). Twenty-three pairs were categorized as leukemia/lymphoma (66%), eight as solid tumors (23%), and four as HSCT (11%). Thirty-four pairs (97%) had a presenting ANC < 500 cells/µL. Higher temperature one-hour post-acetaminophen was associated with bacteremia (p = 0.04). Logistic regression demonstrated that temperature one-hour post-acetaminophen had a significant predictive value for bacteremia (p = 0.011). The area under the receiver operating characteristic curves for logistic regression and classification and regression tree analysis were 0.70 and 0.71, respectively. CONCLUSION While temperature one-hour post-acetaminophen was higher among patients with bacteremia and was a significant predictor of bacteremia, fever response in isolation lacks sufficient predictive value to impact clinical decision-making. Future studies are needed to assess fever responsiveness as an adjunct to existing modalities of FN risk stratification.
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Coyne CJ, Castillo EM, Shatsky RA, Chan TC. Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:985. [PMID: 35893100 PMCID: PMC9329824 DOI: 10.3390/medicina58080985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.
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Affiliation(s)
- Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
| | - Edward M. Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
| | - Rebecca A. Shatsky
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA 92037, USA;
| | - Theodore C. Chan
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
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