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Clément L, Hélène D, Maud M, Chrystelle D, Constance B, Fréderic M, France R, Pilar GHM, José-Miguel TD, Blandine R. Safety of empirical antibiotic therapy discontinuing for fever of unknown origin during high-risk neutropenia in children. J Infect 2024; 88:106171. [PMID: 38697268 DOI: 10.1016/j.jinf.2024.106171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND ECIL-2021 recommends discontinuing empirical antibiotic therapy (EAT) in febrile-neutropenic children after 72 h of treatment and at least 24-48 h of apyrexia in the case of fever of unknown origin (FUO). These guidelines are rarely applied to high-risk children's neutropenia. MATERIAL AND METHODS We retrospectively included all consecutive FUO episodes occurring during profound neutropenia ≥ 10 days in children in our institution. We evaluated the safety of EAT discontinuation in patients for whom the ECIL guidelines were followed compared to those for whom they didn't. We used a combined criterion of mortality and intensive care unit admission at 30 days. We identified risk factors for recurrent fever after EAT discontinuation. RESULTS Fifty-one FUO episodes occurred in 37 patients. EAT discontinuation followed ECIL guidelines in 19 (37 %) episodes. No deaths and-or transfers in ICU occurred in the ECIL group. The duration of EAT was shorter by nine days in the group following ECIL guidelines (p < 0.001). We observed 14 (27 %) episodes of recurrent fever. Mucositis was significantly associated with recurrent fever (p < 0.01). CONCLUSION EAT discontinuation seems feasible and safe in FUO during prolonged febrile neutropenia in children. However, mucosal lesions should prompt thorough surveillance due to the risk of recurrent fever.
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Affiliation(s)
- Lemaigre Clément
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France
| | - Deutch Hélène
- Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Meligne Maud
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Dupraz Chrystelle
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | | | - Millot Fréderic
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Roblot France
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France
| | - Gallego-Hernanz Maria Pilar
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Torregrosa-Diaz José-Miguel
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Rammaert Blandine
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France.
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Dessie AS, Lanning M, Nichols T, Delgado EM, Hart LS, Agrawal AK. Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care 2022; 38:e259-e263. [PMID: 32941363 DOI: 10.1097/pec.0000000000002241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.
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Affiliation(s)
| | - Miranda Lanning
- New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Tristan Nichols
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | | | - Anurag K Agrawal
- Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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Cennamo F, Masetti R, Largo P, Argentiero A, Pession A, Esposito S. Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy. CHILDREN 2021; 8:children8121086. [PMID: 34943282 PMCID: PMC8700030 DOI: 10.3390/children8121086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.
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Affiliation(s)
- Federica Cennamo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Prisca Largo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704-790
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Haeusler GM, Phillips R, Slavin MA, Babl FE, De Abreu Lourenco R, Mechinaud F, Thursky KA. Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia. EClinicalMedicine 2020; 23:100394. [PMID: 32637894 PMCID: PMC7329706 DOI: 10.1016/j.eclinm.2020.100394] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. METHODS Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). FINDINGS Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to non-recalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. INTERPRETATION Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN. Recalibration of existing CDRs is a novel way to improve diagnostic performance of CDRs and maintain relevance over time. FUNDING National Health and Medical Research Council Grant (APP1104527).
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria State Government, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Corresponding author: Dr Gabrielle M. Haeusler, Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia, 3000, P: +61 3 9656 5853 F: +61 3 9656 1185.
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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Haeusler GM, Thursky KA, Slavin MA, Babl FE, De Abreu Lourenco R, Allaway Z, Mechinaud F, Phillips R. Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules. EClinicalMedicine 2020; 18:100220. [PMID: 31993576 PMCID: PMC6978200 DOI: 10.1016/j.eclinm.2019.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reduced intensity treatment of low-risk febrile neutropenia (FN) in children with cancer is safe and improves quality of life. Identifying children with low-risk FN using a validated risk stratification strategy is recommended. This study prospectively validated nine FN clinical decision rules (CDRs) designed to predict infection or adverse outcome. METHODS Data were collected on consecutive FN episodes in this multicentre, prospective validation study. The reproducibility and discriminatory ability of each CDR in the validation cohort was compared to the derivation dataset and details of missed outcomes were reported. FINDINGS There were 858 FN episodes in 462 patients from eight hospitals included. Bacteraemia occurred in 111 (12·9%) and a non-bacteraemia microbiological documented infection in 185 (21·6%). Eight CDRs exhibited reproducibility and sensitivity ranged from 64% to 96%. Rules that had >85% sensitivity in predicting outcomes classified few patients (<20%) as low risk. For three CDRs predicting a composite outcome of any bacterial or viral infection, the sensitivity and discriminatory ability improved for prediction of bacterial infection alone. Across all CDRs designed to be implemented at FN presentation, the sensitivity improved at day 2 assessment. INTERPRETATION While reproducibility was observed in eight out of the nine CDRs, no rule perfectly differentiated between children with FN at high or low risk of infection. This is in keeping with other validation studies and highlights the need for additional safeguards against missed infections or adverse outcomes before implementation can be considered.
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Affiliation(s)
- Gabrielle M. Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Corresponding author at: Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne 3000, Australia.
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E. Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT)
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zoe Allaway
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
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Lekshminarayanan A, Bhatt P, Linga VG, Chaudhari R, Zhu B, Dave M, Donda K, Savani S, Patel SV, Billimoria ZC, Bhaskaran S, Zaid-Kaylani S, Dapaah-Siakwan F, Bhatt NS. National Trends in Hospitalization for Fever and Neutropenia in Children with Cancer, 2007-2014. J Pediatr 2018; 202:231-237.e3. [PMID: 30029861 DOI: 10.1016/j.jpeds.2018.06.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/05/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess the trends of inpatient resource use and mortality in pediatric hospitalizations for fever with neutropenia in the US from 2007 to 2014. STUDY DESIGN Using National (Nationwide) Inpatient Sample (NIS) and International Classification of Diseases, Ninth Revision, Clinical Modification codes, we studied pediatric cancer hospitalizations with fever with neutropenia between 2007 and 2014. Using appropriate weights for each NIS discharge, we created national estimates of median cost, length of stay, and in-hospital mortality rates. RESULTS Between 2007 and 2014, there were 104 315 hospitalizations for pediatric fever with neutropenia. The number of weighted fever with neutropenia hospitalizations increased from 12.9 (2007) to 18.1 (2014) per 100 000 US population. A significant increase in fever with neutropenia hospitalizations trend was seen in the 5- to 14-year age group, male sex, all races, and in Midwest and Western US hospital regions. Overall mortality rate remained low at 0.75%, and the 15- to 19-year age group was at significantly greater risk of mortality (OR 2.23, 95% CI 1.36-3.68, P = .002). Sepsis, pneumonia, meningitis, and mycosis were the comorbidities with greater risk of mortality during fever with neutropenia hospitalizations. Median length of stay (2007: 4 days, 2014: 5 days, P < .001) and cost of hospitalization (2007: $8771, 2014: $11 202, P < .001) also significantly increased during the study period. CONCLUSIONS Our study provides information regarding inpatient use associated with fever with neutropenia in pediatric hospitalizations. Continued research is needed to develop standardized risk stratification and cost-effective treatment strategies for fever with neutropenia hospitalizations considering increasing costs reported in our study. Future studies also are needed to address the greater observed mortality in adolescents with cancer.
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Affiliation(s)
- Anusha Lekshminarayanan
- Department of Internal Medicine, Functional Cholesterol, Diabetes, and Endocrinology Center, Springdale, OH
| | - Parth Bhatt
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX
| | - Vijay Gandhi Linga
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX
| | - Riddhi Chaudhari
- Department of Pediatrics, University of Connecticut, Hartford, CT
| | - Brian Zhu
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX
| | - Mihir Dave
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keyur Donda
- Department of Pediatrics, University of Miami, Coral Gables, FL
| | - Sejal Savani
- Department of Public Health, New York University, New York, NY
| | - Samir V Patel
- Department of Internal Medicine, Sparks Health Systems, Fort Smith, AR
| | | | - Smita Bhaskaran
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX
| | - Samer Zaid-Kaylani
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX
| | | | - Neel S Bhatt
- Department of Pediatrics, Division of Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, WI.
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Abstract
BACKGROUND Although febrile neutropenia (FN) is one of the most common adverse events produced by chemotherapy, its microbiological etiology is determined for only 15% to 30% of cases. OBJECTIVES We investigated the rate of viremia with common DNA viruses in patients with FN. STUDY DESIGN From June 2012 to April 2014, 72 blood samples from 24 patients receiving chemotherapy, who experienced FN episodes, were examined for the presence of herpes viruses and other DNA viruses. We used real-time polymerase chain reaction assays to detect herpes simplex virus type 1 and 2, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, human herpes virus types 6 and 7, BK virus and human parvovirus B19 (B19). RESULTS Viruses were identified in 14 of 72 samples (19.4%). The detected etiological agents were BK virus (5 episodes), human herpes virus type 6 (4 episodes), B19 (4 episodes), Epstein-Barr virus (2 episodes), and cytomegalovirus (1 episode). CONCLUSIONS Our results indicate that viral infections are common causes in patients with FN. Therefore, viruses may be responsible for FN in a large proportion of patients in whom a causative microorganism could not be identified, and this viral etiology may explain their poor response to antibiotic therapy.
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Das A, Trehan A, Bansal D. Risk Factors for Microbiologically-documented Infections, Mortality and Prolonged Hospital Stay in Children with Febrile Neutropenia. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1395-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Haeusler GM, Thursky KA, Slavin MA, Mechinaud F, Babl FE, Bryant P, De Abreu Lourenco R, Phillips R. External Validation of Six Pediatric Fever and Neutropenia Clinical Decision Rules. Pediatr Infect Dis J 2018; 37:329-335. [PMID: 28877157 DOI: 10.1097/inf.0000000000001777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fever and neutropenia (FN) clinical decision rules (CDRs) are recommended to help distinguish children with cancer at high and low risk of severe infection. The aim of this study was to validate existing pediatric FN CDRs designed to stratify children with cancer at high or low risk of serious infection or medical complication. METHODS Pediatric CDRs suitable for validation were identified from a literature search. Relevant data were extracted from an existing data set of 650 retrospective FN episodes in children with cancer. The sensitivity and specificity of each of the CDR were compared with the derivation studies to assess reproducibility. RESULTS Six CDRs were identified for validation: 2 were designed to predict bacteremia and 4 to predict adverse events. Five CDRs exhibited reproducibility in our cohort. A rule predicting bacteremia had the highest sensitivity (100%; 95% confidence interval (CI): 93%-100%) although poor specificity (17%), with only 15% identified as low risk. For adverse events, the highest sensitivity achieved was 84% (95% CI: 75%-90%), with specificity of 29% and 27% identified as low risk. A rule intended for application after a 24-hour period of inpatient observation yielded a sensitivity of 80% (95% CI: 73-86) and specificity of 46%, with 44% identified as low risk. CONCLUSIONS Five CDRs were reproducible, although not all can be recommended for implementation because of either inadequate sensitivity or failure to identify a clinically meaningful number of low-risk patients. The 24-hour rule arguably exhibits the best balance between sensitivity and specificity in our population.
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Das A, Trehan A, Oberoi S, Bansal D. Validation of risk stratification for children with febrile neutropenia in a pediatric oncology unit in India. Pediatr Blood Cancer 2017; 64. [PMID: 27860223 DOI: 10.1002/pbc.26333] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/12/2016] [Accepted: 10/07/2016] [Indexed: 11/10/2022]
Abstract
PURPOSE The study aims to validate a score predicting risk of complications in pediatric patients with chemotherapy-related febrile neutropenia (FN) and evaluate the performance of previously published models for risk stratification. PATIENTS AND METHODS Children diagnosed with cancer and presenting with FN were evaluated in a prospective single-center study. A score predicting the risk of complications, previously derived in the unit, was validated on a prospective cohort. Performance of six predictive models published from geographically distinct settings was assessed on the same cohort. RESULTS Complications were observed in 109 (26.3%) of 414 episodes of FN over 15 months. A risk score based on undernutrition (two points), time from last chemotherapy (<7 days = two points), presence of a nonupper respiratory focus of infection (two points), C-reactive protein (>60 mg/l = five points), and absolute neutrophil count (<100 per μl = two points) was used to stratify patients into "low risk" (score <7, n = 208) and assessed using the following parameters: overall performance (Nagelkerke R2 = 34.4%), calibration (calibration slope = 0.39; P = 0.25 in Hosmer-Lemeshow test), discrimination (c-statistic = 0.81), overall sensitivity (86%), negative predictive value (93%), and clinical net benefit (0.43). Six previously published rules demonstrated inferior performance in this cohort. CONCLUSION An indigenous decision rule using five simple predefined variables was successful in identifying children at risk for complications. Prediction models derived in developed nations may not be appropriate for low-middle-income settings and need to be validated before use.
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Affiliation(s)
- Anirban Das
- Pediatric Hematology-Oncology Unit, Tata Medical Center, Kolkata, West Bengal, India
| | - Amita Trehan
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Sapna Oberoi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
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11
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Villanueva MA, August KJ. Early Discharge of Neutropenic Pediatric Oncology Patients Admitted With Fever. Pediatr Blood Cancer 2016; 63:1829-33. [PMID: 27196265 DOI: 10.1002/pbc.26072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fever and neutropenia (FN) is a common complication of pediatric oncology therapy and accounts for a large number of hospital admissions. Standard therapy for FN includes hospital admission and empiric antibiotics. Strict adherence to this practice leads to prolonged hospitalizations that may be unnecessary for patients at low risk of having an underlying significant infection. PROCEDURE Children admitted with FN could be discharged after a minimum of 48 hr with no further antibiotic therapy once they had been afebrile for 24 hr with negative blood cultures from initial presentation, regardless of their neutrophil count. We performed a retrospective review with regard to readmissions and subsequent documented infections in FN patients discharged with an ANC of ≤500 cells/mm(3) . RESULTS There were 299 FN admissions in 188 patients who were discharged prior to achieving an ANC of ≥500 cells/mm(3) . Readmission to the hospital during the same period of neutropenia occurred in 50 cases (16.7%) with 27 infections diagnosed in 21 patients. Patients discharged with an ANC of ≤100 cells/mm(3) (odds ratio 3.7) and patients with acute lymphoblastic leukemia (odds ratio 2.6) were more likely to be readmitted for fever. All patients that developed a significant infection had an ANC of ≤100 cells/mm(3) at admission and discharge. In patients that developed a significant infection, only one required admission to the intensive care unit with no deaths. CONCLUSIONS The practice of discharging patients with persistent neutropenia who are afebrile with negative blood cultures produces acceptable rates of readmission and subsequent infection and does not lead to increased morbidity and mortality.
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Demirkaya M, Tugcu D, Akcay A, Aydogan G, Akıcı F, Salcioglu Z, Ekmekci H, Sevinir B, Balci Ekmekci O. Adrenomedullin--A New Marker in Febrile Neutropenia: Comparison With CRP and Procalcitonin. Pediatr Hematol Oncol 2016; 32:482-9. [PMID: 26271020 DOI: 10.3109/08880018.2015.1057310] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In this study, we aimed to determine serum adrenomedullin levels and compare them with levels of C-reactive protein (CRP) and procalcitonin (PCT). Cancer patients aged 0-18 years who experienced febrile neutropenia attacks were included in the study. Adrenomedullin, CRP, and PCT were analyzed at admission, day 3, and days 7-10 later. Fifty episodes of febrile neutropenia that developed in 37 patients were analyzed in this study. The mean age of the patients was 7.5 ± 4.7 (1-18) years. The patients had leukemia (73%), solid tumors (19%), and lymphoma (8%). The percentages of the patients in the clinically documented infection (CDI), fever of unknown origin (FUO), sepsis, and microbiological documented infection (MDI) categories were 34%, 34%, 20%, and 12%, respectively. During the study period, four patients were lost. In the MDI group, adrenomedullin levels on day 3 were significantly higher than those in the CDI and FUO groups. PCT levels were significantly higher in the sepsis group than those in the CDI group at admission, day 3, and days 7-10. In the sepsis group, PCT levels on days 7-10 days were significantly higher than those in the sepsis group. PCT values from the deceased patients on days 7-10 were significantly higher than those from patients who survived. CRP levels did not differ significantly among the febrile neutropenia groups. First, in our study, adrenomedullin was used as a biomarker in the febrile neutropenia episodes of children with cancer. Among adrenomedullin, CRP, and PCT, procalcitonin demonstrates the highest correlation with the severity of infection.
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Affiliation(s)
- Metin Demirkaya
- a Uludag University , Pediatrics, Faculty of Medicine, Division of Pediatric Oncology , Bursa, Turkey
| | - Deniz Tugcu
- b Istanbul University , Istanbul Medical Faculty, Department of Pediatrics, Division of Hematology/Oncology , Istanbul, Turkey.,c Kanuni Sultan Suleyman Education and Research Hospital, Pediatric Hematology and Oncology , Istanbul, Turkey
| | - Arzu Akcay
- b Istanbul University , Istanbul Medical Faculty, Department of Pediatrics, Division of Hematology/Oncology , Istanbul, Turkey.,c Kanuni Sultan Suleyman Education and Research Hospital, Pediatric Hematology and Oncology , Istanbul, Turkey
| | - Gönül Aydogan
- c Kanuni Sultan Suleyman Education and Research Hospital, Pediatric Hematology and Oncology , Istanbul, Turkey
| | - Ferhan Akıcı
- c Kanuni Sultan Suleyman Education and Research Hospital, Pediatric Hematology and Oncology , Istanbul, Turkey
| | - Zafer Salcioglu
- c Kanuni Sultan Suleyman Education and Research Hospital, Pediatric Hematology and Oncology , Istanbul, Turkey.,d Istanbul Bakirkoy Maternity And Children Diseases Training and Research Hospital, Department of Pediatric Hematology-Oncology , Istanbul, Turkey
| | - Hakan Ekmekci
- e Istanbul University , Cerrahpasa Medical Faculty, Biochemistry , Istanbul, Turkey
| | - Betül Sevinir
- a Uludag University , Pediatrics, Faculty of Medicine, Division of Pediatric Oncology , Bursa, Turkey
| | - Ozlem Balci Ekmekci
- e Istanbul University , Cerrahpasa Medical Faculty, Biochemistry , Istanbul, Turkey
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Risk Factors for Febrile Neutropenia in Children With Solid Tumors Treated With Cisplatin-based Chemotherapy. J Pediatr Hematol Oncol 2016; 38:191-6. [PMID: 26907640 DOI: 10.1097/mph.0000000000000515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Febrile neutropenia (FN) is a common and potentially fatal adverse drug reaction of cisplatin-based chemotherapy (CDDPBC) in pediatric patients. Hence, the aim of this study was to determine the incidence and independent risk factors for FN in pediatric patients with solid tumors treated with CDPPBC. Cohort integration was performed in the first cycle of chemotherapy with CDDPBC and patients were followed up to 6 months after the last cycle. FN was defined according to the Common Terminology Criteria for Adverse Events. Relative risks were calculated with confidence intervals at 95% (95% CI) to determine FN risk factors. Multiple logistic regression was performed to identify independent risk factors. One hundred and thirty-nine pediatric patients (median age 7.4 y, range 0.08 to 17 y) were included in the study. FN incidence was 62.5%. Independent risk factors for FN were chemotherapy regimens including anthracyclines (odds ratio [OR]=19.44 [95% CI, 5.40-70.02), hypomagnesaemia (OR=8.20 [95% CI, 1.81-37.14]), and radiotherapy (OR=6.67 [95% CI, 1.24-35.94]). It is therefore concluded that anthracyclines-containing regimens, hypomagnesaemia, and radiotherapy are independent risk factors for FN in patients receiving CDDPBC.
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14
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Risk-adapted approach for fever and neutropenia in paediatric cancer patients – A national multicentre study. Eur J Cancer 2016; 53:16-24. [DOI: 10.1016/j.ejca.2015.10.065] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/25/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022]
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Caniza MA, Odio C, Mukkada S, Gonzalez M, Ceppi F, Chaisavaneeyakorn S, Apiwattanakul N, Howard SC, Conter V, Bonilla M. Infectious complications in children with acute lymphoblastic leukemia treated in low-middle-income countries. Expert Rev Hematol 2015. [PMID: 26211675 DOI: 10.1586/17474086.2015.1071186] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infections are the most important cause of morbidity and mortality in children treated for acute lymphoblastic leukemia (ALL). The rates of infection-associated mortality are up to 10-times higher in low- and middle-income countries (LMIC) than in high-income countries. The prevention, early recognition and management of infectious complications is especially challenging in LMIC because of disease and poverty-related factors, as well as the shortage of trained personnel, supplies, diagnostic tools and adequate organizational infrastructure. Children in LMIC with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens and opportunistic microorganisms. This review summarizes the challenges of managing the major categories of infections in children receiving treatment for ALL and provides updated practical recommendations for preventing and managing these infections in LMIC.
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Affiliation(s)
- Miguela A Caniza
- a 1 Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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Esbenshade AJ, Di Pentima MC, Zhao Z, Shintani A, Esbenshade JC, Simpson ME, Montgomery KC, Lindell RB, Lee H, Wallace A, Garcia KL, Moons KG, Debra L. F. Development and validation of a prediction model for diagnosing blood stream infections in febrile, non-neutropenic children with cancer. Pediatr Blood Cancer 2015; 62:262-268. [PMID: 25327666 PMCID: PMC4402108 DOI: 10.1002/pbc.25275] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/20/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pediatric oncology patients are at increased risk for blood stream infections (BSI). Risk in the absence of severe neutropenia (absolute neutrophil count [ANC] ≥500/µl) is not well defined. PROCEDURE In a retrospective cohort of febrile (temperature ≥38.0° for >1 hr or ≥38.3°) pediatric oncology patients with ANC ≥500/µl, a diagnostic prediction model for BSI was constructed using logistic regression modeling and the following candidate predictors: age, ANC, absolute monocyte count, body temperature, inpatient/outpatient presentation, sex, central venous catheter type, hypotension, chills, cancer diagnosis, stem cell transplant, upper respiratory symptoms, and exposure to cytarabine, anti-thymocyte globulin, or anti-GD2 antibody. The model was internally validated with bootstrapping methods. RESULTS Among 932 febrile episodes in 463 patients, we identified 91 cases of BSI. Independently significant predictors for BSI were higher body temperature (Odds ratio [OR] 2.36 P < 0.001), tunneled external catheter (OR 13.79 P < 0.001), peripherally inserted central catheter (OR 3.95 P = 0.005), elevated ANC (OR 1.19 P = 0.024), chills (OR 2.09 P = 0.031), and hypotension (OR 3.08 P = 0.004). Acute lymphoblastic leukemia diagnosis (OR 0.34 P = 0.026), increased age (OR 0.70 P = 0.049), and drug exposure (OR 0.08 P < 0.001) were associated with decreased risk for BSI. The risk prediction model had a C-index of 0.898; after bootstrapping adjustment for optimism, corrected C-index 0.885. CONCLUSIONS We developed a diagnostic prediction model for BSI in febrile pediatric oncology patients without severe neutropenia. External validation is warranted before use in clinical practice. Pediatr Blood Cancer 2015;62:262-268. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Adam J. Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN, USA,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - M. Cecilia Di Pentima
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN, USA
| | - Zhiguo Zhao
- Vanderbilt Department of Biostatistics, Nashville, TN, USA,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Ayumi Shintani
- Vanderbilt Department of Biostatistics, Nashville, TN, USA,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Jennifer C. Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN, USA
| | | | | | | | - Haerin Lee
- Vanderbilt School of Medicine, Nashville, TN, USA
| | - Ato Wallace
- Vanderbilt School of Medicine, Nashville, TN, USA
| | | | - Karel G.M. Moons
- Vanderbilt Department of Biostatistics, Nashville, TN, USA,Julius Center for Health Sciences and Primary Care, UMC Utrecht, The Netherlands
| | - Friedman Debra L.
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN, USA,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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Delebarre M, Macher E, Mazingue F, Martinot A, Dubos F. Which decision rules meet methodological standards in children with febrile neutropenia? Results of a systematic review and analysis. Pediatr Blood Cancer 2014; 61:1786-91. [PMID: 24975886 DOI: 10.1002/pbc.25106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/23/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clinical decision rules (CDRs) have sought to identify the few children with chemotherapy-induced febrile neutropenia (FN) really at risk of severe infection to reduce the invasive procedures and costs for those at low risk. Several reports have shown that most rules do not perform well enough to be clinically useful. Our objective was to analyze the derivation methods and validation procedures of these CDRs. PROCEDURE A systematic review using Medline, Ovid, Refdoc, and the Cochrane Library through December 2012 searched for all CDRs predicting the risk of severe infection and/or complications in children with chemotherapy-induced FN. Their methodological quality was analyzed by 17 criteria for deriving and validating a CDR identified in the literature. The criteria published by the Evidence Based Medicine Working Group were applied to the published validations of each CDR to assess their level of evidence. RESULTS The systematic research identified 612 articles and retained 12 that derived CDRs. Overall, the CDRs met a median of 65% of the methodological criteria. The criteria met least often were that the rule made clinical sense, or described the course of action, or that the variables and the CDR were reproducible. Only one CDR, developed in South America, met all methodological criteria and provided the highest level of evidence; unfortunately it was not reproducible in Europe. CONCLUSION Only one CDR developed for children with FN met all methodological standards and reached the highest level of evidence.
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Affiliation(s)
- Mathilde Delebarre
- Pediatric Emergency Unit and Infectious Diseases, UDSL, Lille University Hospital, Lille, France; EA2694, UDSL, Lille University Hospital, Lille, France; Pediatric Hematology Unit, UDSL, Lille University Hospital, Lille, France
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Optimization of continuous infusion of piperacillin-tazobactam in children with fever and neutropenia. Pediatr Infect Dis J 2013; 32:962-4. [PMID: 23629023 DOI: 10.1097/inf.0b013e318298dfb8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The study through Monte Carlo simulation of β-lactam pharmacokinetic/pharmacodynamic target attainment and determination of subsequent serum concentrations of piperacillin-tazobactam administered through continuous infusion to children treated for fever and neutropenia shows that 400 mg/kg/day has the highest probability of target attainment against Pseudomonas aeurginosa in our oncology ward compared with the standard regimen of 300 mg/kg/day.
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Doganis D, Asmar B, Yankelevich M, Thomas R, Ravindranath Y. Predictive factors for blood stream infections in children with cancer. Pediatr Hematol Oncol 2013; 30:403-15. [PMID: 23521175 DOI: 10.3109/08880018.2013.778379] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Blood Stream Infections (BSI) are among the most serious infections in children with cancer and are potentially life threatening. A retrospective study of blood cultures obtained from all newly diagnosed patients--from January 1, 2005 to December 31, 2009--with malignancy was conducted. In this study, our aim was to identify clinical and laboratory variables associated with a BSI in a child with malignancy. Among 1004 separate infection episodes detected in 261 patients, 198 were classified as true BSI (19.7%). Univariate analysis showed that factors such as younger age, race, temperature ≥40°C, presence of chills and hypotension, time interval from the last chemotherapy, treatment for recurrent disease or a history of Stem Cell Transplantation, low hemoglobin, low-Platelets count, and Absolute Neutrophils count less than 4 × 10(9)/L were predictive for a BSI. Patients with a catheter in place and especially if this catheter was tunneled and/or multiple lumen were more likely to have a BSI. Being on antibiotics, the history of a BSI during the previous month and having received a red cell or platelet transfusion during the prior 15 days also increased the likelihood for a BSI. According to a multivariate logistic regression analysis, the factors that remained significant were the younger age, the African American race, the presence of chills or hypotension, the use of tunneled or multiple lumen catheters, the administration of antibiotics during the previous 15 days and a low-PLT count.
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Affiliation(s)
- Dimitrios Doganis
- Hematology/Oncology Division, Children's Hospital of Michigan, School of Medicine, Wayne State University, Detroit, MI, USA.
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Biswal S, Godnaik C. Incidence and management of infections in patients with acute leukemia following chemotherapy in general wards. Ecancermedicalscience 2013; 7:310. [PMID: 23634180 PMCID: PMC3634721 DOI: 10.3332/ecancer.2013.310] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Indexed: 12/02/2022] Open
Abstract
We hypothesise that treating patients with acute leukaemia in general wards, with proper hygienic and sanitary practices, would result in the minimum utilisation of resources as compared with the corresponding patients receiving ICU support. For this study, the acute leukaemia patients on induction chemotherapy were kept in general wards and observed for the incidence of neutropenia, resultant neutropenic febriles, the causative organism, and the effect of empirical antimicrobial treatment protocol on the outcome of such infections. Prophylactic anti-fungal therapy and cotrimoxazole therapy improved the outcome of infections. The therapy of neutropenic fever and infections must be adapted according to the risk factors and should include early empiric antifungal therapy. It was observed that the treatment of such patients in general wards could be managed effectively, with the added advantage of optimum utilisation of resources and in a patient-friendly environment, at a reasonable cost to the patients.
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Bothra M, Seth R, Kapil A, Dwivedi SN, Bhatnagar S, Xess I. Evaluation of predictors of adverse outcome in febrile neutropenic episodes in pediatric oncology patients. Indian J Pediatr 2013; 80:297-302. [PMID: 23255077 DOI: 10.1007/s12098-012-0925-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 11/19/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify predictors associated with adverse outcome in febrile neutropenic episodes among pediatric oncology patients between 1 and 18 y age, to ascertain the prevalence of invasive bacterial or fungal infection/mortality, to determine the common organisms causing invasive bacterial infection in children with febrile neutropenia and to evaluate their current antimicrobial sensitivity pattern. METHODS It was an observational descriptive study conducted between February 2009 through July 2010. Febrile neutropenic episodes satisfying the inclusion criteria were enrolled. Relevant history was taken followed by a detailed clinical examination and laboratory examination. Logistic Regression analysis was used to identify significant predictors of adverse outcome in febrile neutropenic episodes. RESULTS Out of the 155 febrile neutropenic episodes studied, adverse outcome occurred in 53(34 %) of the episodes. History of three or more previous episodes of febrile neutropenia, child being already on oral antibiotics and Chest Radiograph abnormality at presentation were found to be significantly associated with adverse outcome on multivariate logistic regression analysis. Documented invasive bacterial and fungal infection was seen in 27.8 % and 14.2 % episodes. Mortality occurred in 8 (5 %) of episodes. Gram negative bacterial infections were more common. Most common bacteria isolated was Escherichia coli and the commonest gram positive organism isolated was Staphylococcus aureus (MSSA). CONCLUSIONS On multivariate analysis, the variables found to be significantly associated with adverse outcome in febrile neutropenic episodes were three or more previous episodes of febrile neutropenia, child being already on oral antibiotics and Chest Radioraph abnormality at presentation.
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Affiliation(s)
- Meenakshi Bothra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
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Demirkaya M, Celebi S, Sevinir B, Hacımustafaoglu M. Randomized comparison of piperacillin-tazobactam plus amikacin versus cefoperazone-sulbactam plus amikacin for management of febrile neutropenia in children with lymphoma and solid tumors. Pediatr Hematol Oncol 2013; 30:141-8. [PMID: 23301757 DOI: 10.3109/08880018.2012.756565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The objective of this study was to compare the effectiveness of piperacillin-tazobactam (PIP/TAZO) plus amikacin (AMK) (PIP/TAZO+AMK) versus cefoperazone-sulbactam (CS) plus AMK (CS+AMK) for the treatment of febrile neutropenia (FN) in children with cancer. The study was designed prospectively and randomized in 0- to 18-year-old children with lymphoma or solid tumor who were hospitalized with FN diagnosis. Consecutively randomized patients received either PIP/TAZO 360 mg/kg/day in 4 doses plus AMK 15 mg/kg/day in 3 doses or CS 100 mg/kg/day in 3 doses plus AMK 15 mg/kg/day in 3 doses intravenously. Treatment modification was defined as any change in the initial empirical antibiotic therapy. A total of 116 FN episodes were managed in 46 patients (26 boys and 20 girls) with a median age of 6.5 years (range .8-17.0) during the study period. Success rates without modification of therapy were 47.5% and 52.6% in PIP/TAZO+AMK group and CS+AMK group, respectively (P >.05). No statistical difference was found between treatment groups in terms of durations of neutropenia, fever, and hospitalization. The overall success rate in all groups was 97.4%. No major side effect was observed in either group during the course of the study. Our study is the first to compare the effectiveness of PIP/TAZO+AMK and CS+AMK therapies. Both combinations were effective and safe as empirical therapy for febrile neutropenic patients.
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Affiliation(s)
- Metin Demirkaya
- Division of Pediatric Oncology, Department of Pediatrics, Medical Faculty, Uludag University, Bursa, Turkey.
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Derivation and validation of a scoring system to identify patients with bacteremia and hematological malignancies at higher risk for mortality. PLoS One 2012; 7:e51612. [PMID: 23272123 PMCID: PMC3522733 DOI: 10.1371/journal.pone.0051612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 11/02/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this study was to develop and validate a reliable clinical prediction rule that could be employed to identify patients at higher likelihood of mortality among those with hematological malignancies (HMs) and bacterial bloodstream infections (BBSIs). METHODS AND FINDINGS We conducted a retrospective cohort study in nine Italian hematological units. The derivation cohort consisted of adult patients with BBSI and HMs admitted to the Catholic University Hospital (Rome) between January 2002 and December 2008. Survivors and nonsurvivors were compared to identify predictors of 30-day mortality. The validation cohort consisted of patients hospitalized with BBSI and HMs who were admitted in 8 other Italian hematological units between January 2009 and December 2010. The inclusion and exclusion criteria were identical for both cohorts, with type and stage of HMs used as matching criteria. In the derivation set (247 episodes), the multivariate analysis yielded the following significant mortality-related risk factors acute renal failure (Odds Ratio [OR] 6.44, Confidential Interval [CI], 2.36-17.57, P<0.001); severe neutropenia (absolute neutrophil count <100/mm(3)) (OR 4.38, CI, 2.04-9.43, P<0.001); nosocomial infection (OR, 3.73, CI, 1.36-10.22, P = 0.01); age ≥65 years (OR, 3.42, CI, 1.49-7.80, P = 0.003); and Charlson Comorbidity Index ≥4 (OR, 3.01, CI 1.36-6.65, P = 0.006). The variables unable to be evaluated at that time (for example, prolonged neutropenia) were not included in the final logistic model. The equal-weight risk score model, which assigned 1 point to each risk factor, yielded good-excellent discrimination in both cohorts, with areas under the receiver operating curve of 0.83 versus 0.93 (derivation versus validation) and good calibration (Hosmer-Lemshow P = 0.16 versus 0.75). CONCLUSIONS The risk index accurately identifies patients with HMs and BBSIs at high risk for mortality; a better initial predictive approach may yield better therapeutic decisions for these patients, with an eventual reduction in mortality.
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Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 2012; 30:4427-38. [PMID: 22987086 DOI: 10.1200/jco.2012.42.7161] [Citation(s) in RCA: 240] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN). METHODS The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations. RESULTS Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented. CONCLUSION This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.
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Azap A, Bozkurt GY, Yüksel MK, Kutlu H, Topçuoğlu P, Aypak A, Akan H. Secondary infections in cancer patients with febrile neutropenia. Turk J Haematol 2012; 29:254-8. [PMID: 24744669 PMCID: PMC3986750 DOI: 10.5152/tjh.2011.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 05/17/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Patients with neutropenia due to cancer chemotherapy are prone to severe infections. Cancer patients canexperience >1 infectious episode during the same period of neutropenia. This study aimed to determine the etiologicaland clinical characteristics of secondary infectious episodes in cancer patients with febrile neutropenia and to identifythe factors associated with the risk of secondary infectious episodes. MATERIAL AND METHODS All cancer patients that received antineoplastic chemotherapy at Ankara University, School ofMedicine, Department of Hematology between May 2004 and May 2005 and developed neutropenia were included in thestudy. Data were collected using survey forms that were completed during routine infectious diseases consultation visits.Categorical data were analyzed using the chi-square test, whereas Student's t-test was used for continuous variables.Multivariate logistic regression analysis was performed to identify independent predictors of secondary infections (SIs). RESULTS SIs were observed during 138 (53%) of 259 febrile neutropenic episodes. Of the 138 episodes, 89 (64.5%)occurred in male patients with a mean age of 40.9 years (range: 17-76 years). In total, 80% of the SIs were clinically ormicrobiologically documented. Factors on d 4 of the initial febrile episode were analyzed via a logistic regression model. The presence of a central intravenous catheter (OR: 3.01; P<0.001), acute myeloid leukemia (AML) as the underlyingdisease (OR: 2.12; P=0.008), diarrhea (OR: 4.59; P=0.005), and invasive aspergillosis (IA) during the initial febrileepisode (OR: 3.96; P=0.009) were statistically significant risk factors for SIs. CONCLUSION Among the cancer patients with neutropenia in the present study, AML as the underlying disease, thepresence of a central venous catheter, diarrhea, and IA during the initial febrile episode were risk factors for thedevelopment of SIs.
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Affiliation(s)
- Alpay Azap
- Ankara University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Gülden Yılmaz Bozkurt
- Ankara University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | | | - Hakan Kutlu
- Ankara University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Pervin Topçuoğlu
- Ankara University, School of Medicine, Department of Hematology, Ankara, Turkey
| | - Adalet Aypak
- Ankara Numune Education and Research Hospital, Department of First Infectious Diseases and Clinical Microbiology, Ankara Turkey
| | - Hamdi Akan
- Ankara University, School of Medicine, Department of Hematology, Ankara, Turkey
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Lüthi F, Leibundgut K, Niggli FK, Nadal D, Aebi C, Bodmer N, Ammann RA. Serious medical complications in children with cancer and fever in chemotherapy-induced neutropenia: results of the prospective multicenter SPOG 2003 FN study. Pediatr Blood Cancer 2012; 59:90-5. [PMID: 21837771 DOI: 10.1002/pbc.23277] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/21/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fever and chemotherapy-induced neutropenia (FN) is the most frequent potentially lethal complication of therapy in children with cancer. This study aimed to describe serious medical complications (SMC) in children with FN regarding incidence, clinical spectrum, and associated characteristics. PROCEDURE Pediatric patients presenting with FN induced by non-myeloablative chemotherapy were observed in a prospective multicenter study. SMC was defined as potentially life-threatening complication (PLTC), transfer to the pediatric intensive care unit (PICU), or death. RESULTS A total of 443 FN episodes were reported from 8 centers. Of these, 411 episodes were reported from 4 centers recruiting consecutively and without bias regarding the risk of complications. They were used for calculation of proportions. An SMC was reported in 23 episodes [5.6%; 95% confidence interval (CI): 3.7-8.1], usually defined by more than one criterion. These were PLTC in 13 episodes, PICU in 22, and death in 3 (mortality, 0.7%; 95% CI: 0.2-2.1). Both a delayed onset of SMC (14 of 23 episodes, 61%) and a biphasic clinical course (11 of 23, 48%) were frequently observed. In a multivariate logistic regression analysis, 4 characteristics were significantly and independently associated with the risk of SMC: diagnosis of acute myeloid leukemia, interval since chemotherapy ≤7 days, severely reduced general condition, and hemoglobin ≥9.0 g/dl at presentation. CONCLUSIONS In children with FN, SMC were rare, and mortality was very low. Those with SMC often had a delayed onset and biphasic clinical course with secondary deterioration.
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Affiliation(s)
- Fabienne Lüthi
- Department of Pediatrics, University of Bern, Bern, Switzerland
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Predicting the risk of severe infection in children with chemotherapy-induced febrile neutropenia. Curr Opin Hematol 2012; 19:39-43. [DOI: 10.1097/moh.0b013e32834da951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The use of antimicrobial agents in children with fever during chemotherapy-induced neutropenia: the importance of risk stratification. Pediatr Infect Dis J 2011; 30:887-90. [PMID: 21915020 DOI: 10.1097/inf.0b013e3182311343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Hakim H, Gaur AH. Initial Management of Fever and Neutropenia in a Child With Cancer—The Past, the Present, and the Future. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Predicting bacteremia in children with cancer and fever in chemotherapy-induced neutropenia: results of the prospective multicenter SPOG 2003 FN study. Pediatr Infect Dis J 2011; 30:e114-9. [PMID: 21394050 DOI: 10.1097/inf.0b013e318215a290] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Demir HA, Kutluk T, Ceyhan M, Yağcı-Küpeli B, Akyüz C, Cengiz B, Varan A, Kara A, Yalçın B, Seçmeer G, Büyükpamukçu M. Comparison of sulbactam-cefoperazone with carbapenems as empirical monotherapy for febrile neutropenic children with lymphoma and solid tumors. Pediatr Hematol Oncol 2011; 28:299-310. [PMID: 21413829 DOI: 10.3109/08880018.2011.552937] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Febrile neutropenia (FEN) is a leading complication of intensive chemotherapy. With this prospective randomized study, the authors aimed to compare the effectiveness of sulbactam-cefoperazone (SC) versus carbapenems, as empirical monotherapy in febrile neutropenic children with lymphoma and solid tumors. Febrile neutropenic children (age ≤16 years) hospitalized at the authors' center for lymphomas or solid tumors between March 2007 and June 2009 were included in the study. Patients randomly received SC or carbapenem. Patients were reevaluated at 72 hours and in case of persistent fever, an aminoglycoside and/or a glycopeptide was added to the antibiotic treatment. When a resistant pathogen was isolated, the antibiotic therapy was modified. Treatment responses was defined as success without modification, overall success, or failure. Two hundred and eight episodes were documented in 128 patients (F/M: 56/72), with a median age of 7 years (0.5-17.4 years). Absolute neutrophil count and duration of neutropenia in patients treated with SC and carbapenems were 133/mm(3) (0-500) and 113/mm(3) (0-500), and 4 days (1-21) and 5 days (2-20), respectively. In the SC and carbapenem groups, 82 (78.8%) and 84 episodes (80.7%) improved with treatment, whereas 21 (20.2%) and 19 (18.3%) episodes required treatment modification respectively. One patient from each treatment group died according to febrile neutropenia. The overall success rates were 99% in both groups (P = .94). Empiric SC therapy was found to be as effective as carbapenem monotherapy in pediatric febrile neutropenic patients with lymphoma and solid tumors.
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Affiliation(s)
- Hacı Ahmet Demir
- Department of Pediatric Oncology, Institute of Oncology, Hacettepe University, Ankara, Turkey
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Phillips B, Wade R, Stewart LA, Sutton AJ. Systematic review and meta-analysis of the discriminatory performance of risk prediction rules in febrile neutropaenic episodes in children and young people. Eur J Cancer 2011; 46:2950-64. [PMID: 20621468 PMCID: PMC2981857 DOI: 10.1016/j.ejca.2010.05.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 05/19/2010] [Accepted: 05/24/2010] [Indexed: 12/20/2022]
Abstract
Introduction Febrile neutropaenia is a frequently occurring and occasionally life-threatening complication of treatment for childhood cancer, yet many children are aggressively over-treated. We aimed to undertake a systematic review and meta-analysis to summarise evidence on the discriminatory ability and predictive accuracy of clinical decision rules (CDR) of risk stratification in febrile neutropaenic episodes. Methods The review was conducted in accordance with Centre for Reviews and Dissemination methods, using random effects models to undertake meta-analysis. It was registered with the HTA Registry of systematic reviews, CRD32009100453. Results We found 20 studies describing 16 different CDR assessed in 8388 episodes of FNP. No study compared different approaches and only one CDR had been subject to testing across multiple datasets. This review cannot conclude that any system is more effective or reliable than any other. Conclusion To maximise the value of the information already collected by these and other cohorts of children with febrile neutropaenia, an individual-patient-data (IPD) meta-analysis is required to develop and test new and existing CDR to improve stratification and optimise therapy.
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Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK.
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Fortún J, Sanz MÁ, Madero L, López J, de la Torre J, Jarque I, Vallejo C. Update on bacteraemia in oncology and hematology. Enferm Infecc Microbiol Clin 2011; 29 Suppl 4:48-53. [DOI: 10.1016/s0213-005x(11)70036-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Abstract
PURPOSE OF REVIEW To provide an update on the rational approach of febrile neutropenia in children with cancer and discuss future research aspects in the field. RECENT FINDINGS Clinical and laboratory variables and new biomarkers associated with an increased risk for a severe outcome including invasive bacterial infection (IBI), sepsis, and mortality have been identified for children with cancer and febrile neutropenia. These variables and biomarkers are currently being used for an early risk assessment in order to identify children at low or high risk for IBI or at high risk for sepsis and death. Early identification of children with a differential risk has allowed the implementation of selective treatment regimens. More recently, host genetic differences have been associated with a differential risk for IBI. The individual gene profile based on selected polymorphisms could further fine-tune the early risk assessment allowing tailor-made management strategies. SUMMARY In the last decades, efforts have focused on the stratification of the heterogeneous group of children with cancer and febrile neutropenia according to their risk for developing an IBI. This effort has allowed a less aggressive treatment strategy for children at low risk, including early hospital discharge and use of intravenous and oral antimicrobials at home. More recently, advances have been made in the early identification of children in the other spectrum of infection, those at high risk for sepsis and mortality, with the aim of rapid implementation of aggressive therapy.
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Abstract
BACKGROUND To identify predictors for 2 risk measures-"proven invasive bacterial infection or culture-negative sepsis (IBD)" and "clinical complications (CC)"-in pediatric cancer patients with fever and neutropenia (FN). METHODS Records of 390 patients with FN hospitalized over 2 years were reviewed. For the 332 who met inclusion criteria, one FN episode was randomly selected. Independent predictors at presentation were analyzed using multiple regression models. Optimal cut-off risk prediction scores were determined. These models were validated by bootstrap analysis. RESULTS Patients' median age was 6.0 years; 66% had an underlying diagnosis of leukemia. Independent predictors of IBD (n = 56) were absolute neutrophil count <100, temperature at presentation > or =39.0 degrees C, "sick" clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <24 reliably identified patients at low risk for IBD. Independent predictors of CC (n = 47) were relapse of malignancy, non-white race, "sick" clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <19 predicted patients at low risk for CC. Of those misclassified as low risk, 11 of 12 with IBD and 3 of 9 with CC had the outcome within 24 hours of presentation. Of the remaining patients classified as low-risk for IBD and CC, 99.5% and 97.1%, respectively, remained outcome-free after 24 hours of observation. CONCLUSIONS This study identifies predictors of infection/complications in pediatric patients with FN, establishes clinical cut-off scores and highlights the importance of the initial clinical impression and 24 hours of observation. These prediction models warrant prospective validation.
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te Poele EM, Tissing WJE, Kamps WA, de Bont ESJM. Risk assessment in fever and neutropenia in children with cancer: What did we learn? Crit Rev Oncol Hematol 2009; 72:45-55. [PMID: 19195908 DOI: 10.1016/j.critrevonc.2008.12.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 12/04/2008] [Accepted: 12/18/2008] [Indexed: 11/15/2022] Open
Abstract
Children with cancer treated with chemotherapy are susceptible to bacterial infections and serious infectious complications. However, fever and neutropenia can also result from other causes, for which no antibiotic treatment is needed. In the past decades attempts have been made to stratify the heterogeneous group of pediatric cancer patients with fever and neutropenia into high- and low-risk groups for bacterial infections or infectious complications. Strategies for risk assessment have resulted in treatment regimens with early discharge or even no hospital admission at all, and/or treatment with oral or no antibiotics. We will provide a historical overview of the changing approach to low-risk fever and neutropenia, and we will also try to identify clear and objective parameters for risk assessment strategies and illustrate their relationship to innate immunity. In the future, new insights into genetic susceptibility on neutropenic fever might be of use in children with cancer with fever and neutropenia.
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Affiliation(s)
- Esther M te Poele
- Department of Pediatrics, Division of Pediatric Oncology/Hematology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
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Wicki S, Keisker A, Aebi C, Leibundgut K, Hirt A, Ammann RA. Risk prediction of fever in neutropenia in children with cancer: a step towards individually tailored supportive therapy? Pediatr Blood Cancer 2008; 51:778-83. [PMID: 18726920 DOI: 10.1002/pbc.21726] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fever in severe chemotherapy-induced neutropenia (FN) is the most frequent manifestation of a potentially lethal complication of current intensive chemotherapy regimens. This study aimed at establishing models predicting the risk of FN, and of FN with bacteremia, in pediatric cancer patients. METHODS In a single-centre cohort study, characteristics potentially associated with FN and episodes of FN were retrospectively extracted from charts. Poisson regression accounting for chemotherapy exposure time was used for analysis. Prediction models were constructed based on a derivation set of two thirds of observations, and validated based on the remaining third of observations. RESULTS In 360 pediatric cancer patients diagnosed and treated for a cumulative chemotherapy exposure time of 424 years, 629 FN were recorded (1.48 FN per patient per year, 95% confidence interval (CI), 1.37-1.61), 145 of them with bacteremia (23% of FN; 0.34; 0.29-0.40). More intensive chemotherapy, shorter time since diagnosis, bone marrow involvement, central venous access device (CVAD), and prior FN were significantly and independently associated with a higher risk to develop both FN and FN with bacteremia. The prediction models explained more than 30% of the respective risks. CONCLUSIONS The two models predicting FN and FN with bacteremia were based on five easily accessible clinical variables. Before clinical application, they need to be validated by prospective studies.
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Affiliation(s)
- Silvia Wicki
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Bern, Bern, Switzerland
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