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Logan LK, Gandra S, Mandal S, Klein EY, Levinson J, Weinstein RA, Laxminarayan R. Multidrug- and Carbapenem-Resistant Pseudomonas aeruginosa in Children, United States, 1999-2012. J Pediatric Infect Dis Soc 2017; 6:352-359. [PMID: 27856730 PMCID: PMC5907855 DOI: 10.1093/jpids/piw064] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is a common cause of healthcare-associated infection. Multidrug-resistant (MDR) (>3 classes) and carbapenem-resistant (CR) P aeruginosa are significant threats globally. We used a large reference-laboratory database to study the epidemiology of P aeruginosa in children in the United States. METHODS Antimicrobial susceptibility data from the Surveillance Network were used to phenotypically identify MDR and CR P aeruginosa isolates in children aged 1 to 17 years between January 1999 and July 2012. Logistic regression analysis was used to calculate trends in the prevalence of MDR and CR P aeruginosa. Isolates from infants (<1 year old) and patients with cystic fibrosis were excluded. RESULTS Among the isolates tested, the crude proportion of MDR P aeruginosa increased from 15.4% in 1999 to 26% in 2012, and the proportion of CR P aeruginosa increased from 9.4% in 1999 to 20% in 2012. The proportion of both MDR and CR P aeruginosa increased each year by 4% (odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03-1.04] and 1.04 [95% CI, 1.04-1.05], respectively). In multivariable analysis, both MDR and CR P aeruginosa were more common in the intensive care setting, among children aged 13 to 17 years, in respiratory specimens, and in the West North Central region. In addition, resistance to other antibiotic classes (aminoglycosides, fluoroquinolones, cephalosporins, and piperacillin-tazobactam) often used to treat P aeruginosa increased. CONCLUSIONS Rates of MDR and CR P aeruginosa infection in children are rising nationally. Aggressive prevention strategies, including instituting antimicrobial stewardship programs in pediatric settings, are essential for combating antimicrobial resistance.
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Affiliation(s)
- Latania K Logan
- Departments of Pediatrics
- Section of Pediatric Infectious Diseases, Rush Medical College, Rush University Medical Center, Chicago, Illinois
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Sumanth Gandra
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | | | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jordan Levinson
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Robert A Weinstein
- Internal Medicine, Division of Infectious Diseases
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Public Health Foundation of India, New Delhi
- Princeton University, Princeton, New Jersey
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Brack E, Bodmer N, Simon A, Leibundgut K, Kühne T, Niggli FK, Ammann RA. First-day step-down to oral outpatient treatment versus continued standard treatment in children with cancer and low-risk fever in neutropenia. A randomized controlled trial within the multicenter SPOG 2003 FN study. Pediatr Blood Cancer 2012; 59:423-30. [PMID: 22271702 DOI: 10.1002/pbc.24076] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/21/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND The standard treatment of fever in chemotherapy-induced neutropenia (FN) includes emergency hospitalization and empirical intravenous antimicrobial therapy. This study determined if first-day step-down to oral outpatient treatment is not inferior to continued standard regarding safety and efficacy in children with low-risk FN. PROCEDURE In a randomized controlled non-blinded multicenter study, pediatric patients with FN after non-myeloablative chemotherapy were reassessed after 8-22 hours of inpatient intravenous antimicrobial therapy. Low-risk patients were randomized to first-day step-down to experimental (outpatient, oral amoxicillin plus ciprofloxacin) versus continued standard treatment. Exact non-inferiority tests were used for safety (no serious medical complication; non-inferiority margin of difference, 3.5%) and efficacy (resolution of infection without recurrence, no modification of antimicrobial therapy, no adverse event; 10%). RESULTS In 93 (26%) of 355 potentially eligible FN episodes low-risk criteria were fulfilled, and 62 were randomized, 28 to experimental (1 lost to follow-up) and 34 to standard treatment. In intention-to-treat analyses, non-inferiority was not proven for safety [27 of 27 (100%) vs. 33 of 34 (97%; 1 death) episodes; 95% upper confidence border, 6.7%; P = 0.11], but non-inferiority was proven for efficacy [23 of 27 (85%) vs. 26 of 34 (76%) episodes; 95% upper confidence border, 9.4%; P = 0.045]. Per-protocol analyses confirmed these results. CONCLUSIONS In children with low-risk FN, the efficacy of first-day step-down to oral antimicrobial therapy with amoxicillin and ciprofloxacin in an outpatient setting was non-inferior to continued hospitalization and intravenous antimicrobial therapy. The safety of this procedure, however, was not assessable with sufficient power.
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Affiliation(s)
- Eva Brack
- Department of Pediatrics, University of Bern, Bern, Switzerland
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Ammann RA, Bodmer N, Hirt A, Niggli FK, Nadal D, Simon A, Ozsahin H, Kontny U, Kühne T, Popovic MB, Lüthy AR, Aebi C. Predicting Adverse Events in Children With Fever and Chemotherapy-Induced Neutropenia: The Prospective Multicenter SPOG 2003 FN Study. J Clin Oncol 2010; 28:2008-14. [DOI: 10.1200/jco.2009.25.8988] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To develop a score predicting the risk of adverse events (AEs) in pediatric patients with cancer who experience fever and neutropenia (FN) and to evaluate its performance. Patients and Methods Pediatric patients with cancer presenting with FN induced by nonmyeloablative chemotherapy were observed in a prospective multicenter study. A score predicting the risk of future AEs (ie, serious medical complication, microbiologically defined infection, radiologically confirmed pneumonia) was developed from a multivariate mixed logistic regression model. Its cross-validated predictive performance was compared with that of published risk prediction rules. Results An AE was reported in 122 (29%) of 423 FN episodes. In 57 episodes (13%), the first AE was known only after reassessment after 8 to 24 hours of inpatient management. Predicting AE at reassessment was better than prediction at presentation with FN. A differential leukocyte count did not increase the predictive performance. The score predicting future AE in 358 episodes without known AE at reassessment used the following four variables: preceding chemotherapy more intensive than acute lymphoblastic leukemia maintenance (weight = 4), hemoglobin ≥ 90 g/L (weight = 5), leukocyte count less than 0.3 G/L (weight = 3), and platelet count less than 50 G/L (weight = 3). A score (sum of weights) ≥ 9 predicted future AEs. The cross-validated performance of this score exceeded the performance of published risk prediction rules. At an overall sensitivity of 92%, 35% of the episodes were classified as low risk, with a specificity of 45% and a negative predictive value of 93%. Conclusion This score, based on four routinely accessible characteristics, accurately identifies pediatric patients with cancer with FN at risk for AEs after reassessment.
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Affiliation(s)
- Roland A. Ammann
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Nicole Bodmer
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Andreas Hirt
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Felix K. Niggli
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - David Nadal
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Arne Simon
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Hulya Ozsahin
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Udo Kontny
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Thomas Kühne
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Maja Beck Popovic
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Annette Ridolfi Lüthy
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
| | - Christoph Aebi
- From the Institute for Infectious Diseases and Department of Pediatrics, University of Bern, Bern; Divisions of Oncology and Infectious Diseases and Hospital Epidemiology, Department of Pediatrics, University of Zurich, Zurich; Department of Pediatrics, University of Geneva, Geneva; University Children's Hospital Basel; Department of Pediatrics, University of Lausanne, Lausanne, Switzerland; Department of Pediatric Hematology and Oncology, University of Bonn, Bonn; and Department of Pediatrics,
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