Risk prediction in pediatric cancer patients with fever and neutropenia

Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit

OBJECTIVE

To describe the clinical course, resource use, and mortality of patients with leukemia admitted to the pediatric intensive care unit with sepsis and nonsepsis diagnoses over a 10-yr period.

DESIGN

Retrospective analysis.

SETTING

Tertiary medical-surgical pediatric intensive care unit at C.S. Mott Children's Hospital, University of Michigan.

PATIENTS

All patients with leukemia admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 2008.

INTERVENTIONS

None; chart review.

MEASUREMENTS AND MAIN RESULTS

Clinical course was characterized by demographics, leukemia diagnosis, phase of therapy, leukocyte count on admission, presence of sepsis, steroid administration, intensity of care, and Pediatric Risk of Mortality score on admission to the pediatric intensive care unit. The primary outcome was survival to pediatric intensive care unit discharge. Among 68 single admissions to the pediatric intensive care unit with leukemia during the study period, 33 (48.5%) were admitted with sepsis. Admission to the pediatric intensive care unit for sepsis was associated with greater compromise of hemodynamic and renal function and use of stress dose steroids (p = .016), inotropic and/or vasopressor drugs (p = .01), and renal replacement therapy (p = .028) than nonsepsis admission. There was higher mortality among children with sepsis than other diagnoses (52% vs. 17%, p = .004). Also, mortality among children with sepsis was higher among those with acute lymphoblastic leukemia (60% vs. 44%) compared with acute myelogenous leukemia. Administration of stress dose steroids was associated with higher mortality (50% vs. 17%, p = .005) and neutropenia. Patients with acute lymphoblastic leukemia and sepsis showed the greatest mortality and resource use.

CONCLUSIONS

Patients with acute leukemia and sepsis had a much higher mortality rate compared with previously described sepsis mortality rates for the general pediatric intensive care unit patient populations. Patients who received steroids had an increased mortality rate, but given the retrospective nature of this study, we maintain a position of equipoise with regard to this association. Variation in mortality and resource use by leukemia type suggests further research is needed to develop targeted intervention strategies to enhance patient outcomes.

The use of antimicrobial agents in children with fever during chemotherapy-induced neutropenia: the importance of risk stratification

Children with fever and chemotherapy-induced or cancer-associated neutropenia should be assessed with complete history and physical examinations, undergo appropriate diagnostic studies, and promptly receive broad-spectrum empirical antimicrobial therapy. Assessment of risk for severe infection is crucial in determining the appropriate antimicrobial, route, venue, and duration of empirical antimicrobial therapy and need for prophylactic antimicrobial agents.

Predicting bacteremia in children with cancer and fever in chemotherapy-induced neutropenia: results of the prospective multicenter SPOG 2003 FN study

STUDY AIM

To develop a score predicting the risk of bacteremia in cancer patients with fever and neutropenia (FN), and to evaluate its performance.

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 bacteremia was developed from a multivariate mixed logistic regression model. Its cross-validated predictive performance was compared with that of published risk prediction rules.

RESULTS

Bacteremia was reported in 67 (16%) of 423 FN episodes. In 34 episodes (8%), bacteremia became known only after reassessment after 8 to 24 hours of inpatient management. Predicting bacteremia at reassessment was better than prediction at presentation with FN. A differential leukocyte count did not increase the predictive performance. The reassessment score predicting future bacteremia in 390 episodes without known bacteremia used the following 4 variables: hemoglobin ≥ 90 g/L at presentation (weight 3), platelet count <50 G/L (3), shaking chills (5), and other need for inpatient treatment or observation according to the treating physician (3). Applying a threshold ≥ 3, the score--simplified into a low-risk checklist--predicted bacteremia with 100% sensitivity, with 54 episodes (13%) classified as low-risk, and a specificity of 15%.

CONCLUSIONS

This reassessment score, simplified into a low-risk checklist of 4 routinely accessible characteristics, identifies pediatric patients with FN at risk for bacteremia. It has the potential to contribute to the reduction of use of antimicrobials in, and to shorten the length of hospital stays of pediatric patients with cancer and FN.

Heme-onc emergencies

January of 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this new certification, three times a year JEN will feature this new column supplying questions similar to those in the CPEN examination to assist in preparation for the examination. Questions, rationale for the correct answers, and references are provided here for your self-evaluation.

Current understanding of fever and host immunity

PURPOSE OF REVIEW

Inherited and acquired immune system dysfunctions associated with fever are reviewed. Recent evidence of best practices in the diagnosis and treatment of fever caused by infections in children are also discussed.

RECENT FINDINGS

Descriptive studies on clinical presentation of periodic fever and outcomes associated with and without interventions are discussed. Diagnostic evaluation and therapy of fever and neutropenia in cancer patients and challenges associated with the diagnosis of Kawasaki disease are also included. New evidence on the treatment of urinary tract infection in the neonate, and clinical evaluation tools for febrile infants, are reviewed.

SUMMARY

Immune-dysfunction as a cause of fever is not well understood. In order to target therapy appropriately, more studies are needed to understand the pathogenesis of fever in this population. Better diagnostic methods are available for detection of viruses, especially in patients with fever and neutropenia, but further investigation is required for the interpretation of those results.