Preventing Infections in Children with Cancer

Levofloxacin prophylaxis in hospitalized children with leukemia: A cost-utility analysis

BACKGROUND

Infections are common and are a major cause of morbidity and mortality during treatment of childhood leukemia. We evaluated the cost effectiveness of levofloxacin antibiotic prophylaxis, compared to no prophylaxis, in children receiving chemotherapy for acute myeloid leukemia (AML) or relapsed acute lymphoblastic leukemia (ALL).

PROCEDURES

A cost-utility analysis was conducted from the perspective of the single-payer health care system using a lifetime horizon. A comprehensive literature review identified available evidence for effectiveness, safety, costs of antibiotic prophylaxis in children with leukemia, and health utilities associated with the relevant health states. The effects of levofloxacin prophylaxis on health outcomes, quality-adjusted life-years (QALY), and direct health costs were derived from a combined decision tree and state-transition model. One-way deterministic and probabilistic sensitivity analyses were performed to test the sensitivity of results to parameter uncertainty.

RESULTS

The literature review revealed one randomized controlled trial on levofloxacin prophylaxis in childhood AML and relapsed ALL, by Alexander et al, that showed a significant reduction in rates of fever and neutropenia (71.2% vs 82.1%) and bacteremia (21.9% vs 43.4%) with levofloxacin compared to no prophylaxis. In our cost-utility analysis, levofloxacin prophylaxis was dominant over no prophylaxis, resulting in cost savings of $542.44 and increased survival of 0.13 QALY. In probabilistic sensitivity analysis, levofloxacin prophylaxis was dominant in 98.8% of iterations.

CONCLUSIONS

The present analysis suggests that levofloxacin prophylaxis, compared to no prophylaxis, is cost saving in children receiving intensive chemotherapy for AML or relapsed ALL.

Epidemiology and clinical characteristics of viral infections in hospitalized children and adolescents with cancer in Lebanon

Background

Viral infections in children and adolescents with malignancy are commonly encountered and have a significant impact on morbidity and mortality. Studies and epidemiological data regarding viral infections in children with cancer in developing countries are lacking. This retrospective cohort study aims to assess the burden of viral infections in children and adolescents with cancer, by assessing prevalence, risk factors, as well as morbidity and mortality of common viruses over a period of 8 years.

Methods and findings

Medical records of cancer patients treated at the Children Cancer Center of Lebanon were reviewed and 155 participants under the age of 21 were identified with at least one documented viral infection during the period from July 2009 to November 2017. This subset included 136 participants with active malignancy and 19 participants with a history of cancer who underwent hematopoietic stem cell transplantation [HSCT] and were in remission; the latter group was analyzed separately. Information regarding participant characteristics, hospital course, and complications were obtained. Associations between viral infections and certain factors were assessed. In the cohort, 64% were male, 81% were Lebanese. In participants with active malignancy, 90% received chemotherapy in the 6 months preceding the viral infection episode, 11% received radiotherapy. 51% of participants were neutropenic at the time of viral detection, and 77% were lymphopenic. 17% experienced a bacterial co-infection, and 3 experienced a viral co-infection. Among 162 viral infection episodes, clinically diagnosed skin infections, mainly herpes simplex virus type 1 and varicella-zoster virus, were the most common [44% of cases]. These were followed by laboratory-proven systemic herpes infections: cytomegalovirus [14%] and Epstein-Barr virus [6%]. Respiratory viruses: influenza and respiratory syncytial virus, accounted for 9% and 4%, respectively, whereas rotavirus represented 11% and BK virus represented 3% of cases. Acute lymphocytic leukemia was the most prevalent neoplasia [57%]. Fever was the most common presenting symptom [55%] and febrile neutropenia was the reason for admission in 24% of cases. The mean length of stay was significantly longer in participants with cytomegalovirus infections and significantly lower in rotavirus infection. Admission to the ICU occurred in 9%, complications in 8%, and mortality in 5%. Participants with viral infections post-HSCT were noted to have a significantly longer length of hospital stay compared to non-HSCT participants, with no other significant differences in clinical course and outcome. The study was limited by its retrospective nature and by the late introduction and underuse of multiplex PCR panels, which may have led to underdiagnosis of viral infections.

Conclusions

Viral infections were prevalent in our sample of cancer patients and may have contributed to morbidity and mortality. Newly available viral diagnostics are likely to vastly increase the number and scope of detectable viral infections in this population. Prospective studies using multiplex PCR technology with systematic testing of patients will be more helpful in defining the burden of viral infections. Furthermore, efforts at antimicrobial stewardship would benefit from the identification of viral causes of infection and limit the unnecessary use of antibiotics in the pediatric cancer population.

Pneumocystis jiroveci pneumonia in Taiwan from 2014 to 2017: Clinical manifestations and outcomes between pediatric and adult patients

BACKGROUND

Pneumocystis jiroveci pneumonia (PJP) is a severe and lethal opportunistic infection in the immunocompromised patients. As the increasing usage of immunosuppressants, the incidence of non-HIV related PJP has increased in recent years. Still, there is little research regarding children with PJP. The aim of this study is to understand PJP more among pediatric population.

METHODS

We reviewed the medical records of the patients with PJP in National Taiwan University Hospital from 2014 to 2017. Diagnosis was made if the patient met all of the criteria: presence of relevant pulmonary symptoms and signs, pulmonary infiltrates on images, detection of Pneumocystis jiroveci from respiratory specimens via polymerase chain reaction (PCR), and received antibiotics for PJP.

RESULTS

Twenty children and 132 adults were enrolled in this study. The most common underlying diseases among children included malignancy (40%), post-transplantation (30%), and primary immunodeficiency (20%). The major underlying diseases in adults included malignancy (36%), HIV with acquired immunodeficiency syndrome (AIDS) (31%), and autoimmune diseases (24%). There is no significant difference in the clinical manifestations, mortality, and complication between children and adults, but children tended to have less chance of using alternative antibiotics, methylprednisolone and inhaled nitric oxide (NO). The chance of concomitant cytomegalovirus disease was also significantly lower in pediatric patients.

CONCLUSION

No significant difference was found in the clinical manifestations, mortality, and complication between children and adults, but children tended to have lesser chance of using alternative antibiotics, methylprednisolone and inhaled NO. The chance of associated cytomegalovirus (CMV) disease was also significantly lower in children.