Neonatal bloodstream infections in a pediatric hospital in Vietnam: a cohort study

Septicemia and bloodstream infections (BSIs) are major causes of neonatal morbidity and mortality in developing countries. We prospectively recorded all positive blood cultures (BSI) among neonates admitted consecutively to a tertiary pediatric hospital in Vietnam during a 12-month period. Among 5763 neonates, 2202 blood cultures were performed, of which 399 were positive in 385 neonates. Among these, 64 died, 62 in relation to septicemia. Of the BSI isolates, 56% was known pathogenic and 48% was gram-negative bacteria, most frequently Klebsiella spp. (n = 78), Acinetobacter spp. (n = 58) and Escherichia coli (n = 21). Only three Streptococcus spp. were identified, none group B. Resistance against antibiotics applied was common. The mortality was highest in neonates with gram-negative BSI compared with no confirmed BSI and gram-positive BSI (P < 0.01). In this setting, the majority of BSI were likely to have been transmitted from the environment. Improvement of hygienic precautions and systematic BSI surveillance are recommended.

Clinical features, antimicrobial susceptibility patterns and genomics of bacteria causing neonatal sepsis in a children's hospital in Vietnam: protocol for a prospective observational study

INTRODUCTION

The clinical syndrome of neonatal sepsis, comprising signs of infection, septic shock and organ dysfunction in infants ≤4 weeks of age, is a frequent sequel to bloodstream infection and mandates urgent antimicrobial therapy. Bacterial characterisation and antimicrobial susceptibility testing is vital for ensuring appropriate therapy, as high rates of antimicrobial resistance (AMR), especially in low-income and middle-income countries, may adversely affect outcome. Ho Chi Minh City (HCMC) in Vietnam is a rapidly expanding city in Southeast Asia with a current population of almost 8 million. There are limited contemporary data on the causes of neonatal sepsis in Vietnam, and we hypothesise that the emergence of multidrug resistant bacteria is an increasing problem for the appropriate management of sepsis cases. In this study, we aim to investigate the major causes of neonatal sepsis and assess disease outcomes by clinical features, antimicrobial susceptibility profiles and genome composition.

METHOD AND ANALYSIS

We will conduct a prospective observational study to characterise the clinical and microbiological features of neonatal sepsis in a major children's hospital in HCMC. All bacteria isolated from blood subjected to whole genome sequencing. We will compare clinical variables and outcomes between different bacterial species, genome composition and AMR gene content. AMR gene content will be assessed and stratified by species, years and contributing hospital departments. Genome sequences will be analysed to investigate phylogenetic relationships.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the principles of the Declaration of Helsinki and the International Council on Harmonization Guidelines for Good Clinical Practice. Ethics approval has been provided by the Oxford Tropical Research Ethics Committee 35-16 and Vietnam Children's Hospital 1 Ethics Committee 73/GCN/BVND1. The findings will be disseminated at international conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN69124914; Pre-results.

Provider Perceptions of a Novel Inpatient Co-Rounding Model Integrating Medical Oncology, Neuro-Oncology, and Radiation Oncology for the Care of Patients with Advanced Cancer

PURPOSE/OBJECTIVE(S)

Patients (pts) with advanced cancer require interdisciplinary care. Although tumor boards are well-established in the outpatient setting, few studies have evaluated interventions for improving consultative care coordination for hospitalized pts with cancer. The purpose of this study was to evaluate a novel inpatient co-rounding model of care in which medical-, neuro-, and radiation-oncology consult teams rounded jointly, with the hypothesis that primary referring team perception of the alignment of the recommendations from these consult services would improve post-implementation.

MATERIALS/METHODS

An inpatient co-rounding model was implemented in September 2021 for hospitalized pts with solid malignancies at a tertiary medical center. Attending physicians, nurse practitioners, fellows, and residents from oncologic consulting services met virtually twice weekly to discuss pt care. Providers from the two most common primary services for pts with cancer at this hospital (hospital medicine and neurosurgery) were surveyed via institutional email listservs. The survey included Likert-type questions about the quality of inpatient consultation and the alignment of recommendations across three consulting oncological specialty services. The pre-intervention survey was distributed prior to model implementation, and the post-intervention survey was distributed 9 months later. Wilcoxon rank-sum tests were used to compare responses from the pre-and post-intervention surveys.

RESULTS

At each session, a median of 6 providers attended (range, 4-8 providers), and a median of 6 pts were discussed (range, 4-8 pts). Among 331 providers surveyed, 119 completed the pre-intervention survey (36% response rate), and 34 completed the post-intervention survey (10% response rate). Respondents were 81 (53%) internal medicine attending physicians/hospitalists, 55 (36%) internal medicine resident physicians, 6 (4%) neurosurgery advanced practice providers, 6 (4%) neurosurgery attending physicians, and 5 (3%) neurosurgery resident physicians. When asked to rate agreement with the statement that consultant recommendations from medical-, neuro-, and radiation-oncology were aligned, respondents were significantly more likely to perceive alignment 9 months post-implementation (67% strongly agree) compared to pre-implementation (23% strongly agree, p = 0.0001). There was high satisfaction with the quality of medical-, neuro-, and radiation-oncology consultations at both time points, with no statistical difference pre- vs. post-implementation of the co-rounding model.

CONCLUSION

A novel inpatient co-rounding model of care was successfully launched between medical-, neuro-, and radiation-oncology. Primary teams perceived greater alignment in recommendations between these consulting services after project implementation. Future directions include evaluating the impact of this co-rounding model on patient outcomes.

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Acute and Late Toxicities in Patients with Collagen Vascular Disease Receiving Curative-Intent Intensity-Modulated Radiotherapy to the Head and Neck Region

PURPOSE/OBJECTIVE(S)

Historically, collagen vascular disease (CVD) was considered at least a relative contraindication to radiotherapy (RT). However, more recent meta-analyses suggest that for patients with certain CVDs such as rheumatoid arthritis (RA), there may not be an increased risk for severe toxicities, while for patients with CVDs such as systemic lupus erythematosus (SLE), dermatomyositis (DM) and scleroderma, there may be as high as a 2- to 4-fold risk for severe toxicities compared to patients without CVD. There are also data to suggest that patients with head and neck cancer (HNC) and comorbid CVD are at especially high risk of severe toxicities from RT. This study evaluated the hypothesis that among patients with HNC treated with curative-intent intensity-modulated radiation therapy (IMRT), patients with SLE or DM were more likely to have had late grade ≥3 toxicity rates compared to patients with other CVDs.

MATERIALS/METHODS

A total of 23 patients who had HNC with comorbid CVD and received IMRT between 2005-2022 were included. Acute (≤90 days after completion of RT) and late (>90 days) toxicities were retrospectively classified using CTCAE v5.0. Toxicity rates were compared across CVD groups using Chi-squared tests.

RESULTS

Median follow-up was 56.3 months. The most common CVDs were RA (9 patients, 39%), SLE (4 patients, 17%), and DM (4 patients, 17%). Median total RT dose was 66 Gy (range: 48-70 Gy), in 1.8-2.4 Gy fractions. Nine (39%) patients received concurrent chemotherapy. 14 (61%) patients had mucosal squamous cell carcinoma (SCC), 3 (13%) had cutaneous SCC, 2 (9%) had nasal cavity/paranasal sinus tumors, 2 (9%) had salivary gland tumors, 1 (4%) had cutaneous melanoma, and 1 (4%) had mucosal melanoma. Eight (35%) patients experienced acute grade ≥3 toxicities, and 3 (13%) patients experienced late grade ≥3 toxicities (Table 1). No patients had grade≥4 toxicities. Patients with SLE or DM did not have significantly higher risk of late grade ≥3 toxicities compared to those with other CVDs (25% vs. 7%, p = 0.21).

CONCLUSION

In this small sample size of patients with HNC and comorbid CVD, definitive or post-operative IMRT was associated with approximately 35% acute and 15% late severe toxicity rates. While SLE/DM were associated with >3-fold late grade ≥3 toxicities, this association needs to be confirmed with larger data sets.

Dosimetric Analysis Using Automated Tools of Trigeminal Neuralgia Treatment with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Symptoms from trigeminal neuralgia (TGN) can be significantly debilitating. For treatment of TGN with stereotactic radiosurgery (SRS), there is some data that suggests dose and location of treatment along the trigeminal nerve (TN) pathway may be associated with improved outcomes; however, recurrence rates are widely variable. Limited data exists to evaluate dosimetric parameters of SRS for TGN in relation to patient outcome. This study evaluated the hypothesis that specific characteristics of high dose volume coverage of the TN was associated with outcomes in the treatment of TGN with SRS.

MATERIALS/METHODS

Patients who underwent a non-invasive stereotactic radiosurgery instrument for the treatment of TGN at a single institution from 2008-2020 were retrospectively reviewed. Patients were selected for treatment with SRS after consensus from neurosurgery and radiation oncology teams. Patient must have undergone MR FIESTA sequence imaging for treatment planning and had at least 3mo TGN follow up after SRS. Using commercially available software, an automated script was developed to extract detailed characteristics of isodose line structures (IDL) created from the delivered radiation treatment plan. Variables evaluated included voxel volume, mean/max of the HU signal, kurtosis/skewness (a measure of non-spheroidicity) of the IDL, and HU integral of the 140-195% IDL structures, all of which could serve as possible surrogates to the degree and shape of TN pathway dosimetric coverage. Patient reported pain was graded prior and post treatment using Barrow Neurologic Institute pain scale (BNI). Post SRS BNI score I-III was considered significant symptom improvement while BNI score IV-V was considered no benefit. Univariate and multivariable analysis was performed using the cox proportional hazard model.

RESULTS

Of the 73 patients included, 52 (71%) were female and 21 (29%) were male, and median age at time of treatment was 73 years (60-79 years). Pretreatment BNI scores were BNI III in 9 (12%) patients, BNI IV in 42 (58%) patients, and BNI V in 22 (30%) patients. After SRS, 62 (85%) patients experienced significant symptom relief (BNI I-III). Median time to symptom relief was 2mo (IQR 1-4mo) with a median duration of 12mo (2-28mo). Median time to treatment failure was 12mo (IQR 2-28mo). On multivariable analysis evaluating IDL characteristics associated with achieving symptom relief, 195% IDL kurtosis was associated with increased likelihood of achieving symptom relief (HR 1.94, p<.001), while and 180% IDL voxel size was associated with reduced likelihood of achieving symptom relief (HR 0.99, p<.001).

CONCLUSION

In the treatment of TGN with SRS, these initial results suggests that high dose IDL structure characteristics, specifically the size and shape features of the dose distributions, may be associated with likelihood of achieving symptom relief. Future directions include analysis of a richer set of dosimetric features in a larger cohort to further refine significant dosimetric parameters for treatment planning.

Toxicity and Dosimetric Analysis of Reirradiation of Head and Neck Cancers with High Dose Rate Brachytherapy

PURPOSE/OBJECTIVE(S)

Reirradiation (reRT) of recurrent or second primary head and neck cancers (HNC) after prior curative-intent external beam radiotherapy (EBRT) has historically achieved local control (LC) rates of 40-50% and been associated with high grade toxicity rates estimated at 25-50%. This study evaluated the hypothesis that patients with small reRT target volumes could be selected for high dose rate brachytherapy (HDR-BT) reRT and achieve similar LC without excess toxicity.

MATERIALS/METHODS

Included were all patients with HNC squamous cell carcinoma treated with HDR-BT after having previously received curative-intent EBRT for primary HNC from 2000-2021. Patients were selected by a multidisciplinary tumor board to be appropriate candidates for HDR-BT reRT without EBRT generally for definitive or adjuvant treatment of small primary tumors without neck nodal metastases. Univariate analysis was performed using the logistic regression model. Survival outcomes were estimated with the Kaplan Meier method.

RESULTS

Twenty-three patients were evaluated. Median follow up time was 19mo. Median age at time of HDR-BT was 64 years. Thirteen patients (57%) were treated for recurrent HNC, of which 7 were in the oral cavity (OC) and 6 were the oropharynx (OPX). Ten patients (43%) were treated for a second primary HNC, of which 5 were in the OC and 5 were in the OPX. Median time from completion of EBRT to HDR-BT was 41 (IQR 14-73) mo. Within their reRT course, 11 patients (48%) were treated with HDR-BT after resection, 9 patients (39%) received concurrent hyperthermia, and 7 patients (30%) received chemotherapy. HDR-BT regimens included 600cGy x5 (N = 11), 600cGy x6 (N = 6), 450cGy x8 (N = 1), 1500cGy x1 (N = 1),1000cGy x1 (N = 1), 500cGy x8 (N = 1), and 700cGy x5 (N = 1). One patient who was treated with two implants received 450cGy x 3 followed by 475cGy x5. A median of 5 brachytherapy catheters were used. Actuarial 2-year LC and overall survival rate was 68% and 62%, respectively. Of the 17 HDR-BT reRT plans available for review, median (IQR) target volume was 15.8 (10.6-34.9) cc. Median (IQR) target V100% was 90.6 (89.4-90.0)%, V150% was 50.5 (49.7-54.4)%, and V200% was 25.4 (23.8-29.0)%. Median (IQR) target D90% was 30.1 (29.8-35.5) Gy, and median D1cc was 116.4 (100.5-171.4) Gy. The mandible dose [median (IQR)] was D2cc:15.1(9.48-18.9) Gy; D1cc:16.9(11.1-21.3) Gy; and D1%:18.8(13.4-22.7) Gy. Nine of the 23 patients (39%) experienced ≥G3 toxicity including fistula, soft tissue necrosis, osteoradionecrosis, ulcer, hemorrhage, and dysphagia requiring a chronic feeding tube. Target D90% was associated with ≥G3 toxicity (p = 0.045). For D90% greater than the median of 30Gy, 45% ≥G3 toxicity was observed.

CONCLUSION

This study suggests that HDR-BT for reRT of small recurrent or second primary HNC can provide similar LC without excess high-grade toxicities as compared to historical outcomes with EBRT reRT. Delivery of equivalent doses higher than 30Gy in 5 fractions should be approached with caution.