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Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [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: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
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Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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Probst V, Smedegaard LM, Simonyan A, Guo Y, Østrup O, Dungu KHS, Vissing NH, Nygaard U, Bagger FO. A Protocol for Low-Input RNA-Sequencing of Patients with Febrile Neutropenia Captures Relevant Immunological Information. Int J Mol Sci 2023; 24:10251. [PMID: 37373397 DOI: 10.3390/ijms241210251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/05/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Improved methods are needed for diagnosing infectious diseases in children with cancer. Most children have fever for other reasons than bacterial infection and are exposed to unnecessary antibiotics and hospital admission. Recent research has shown that host whole blood RNA transcriptomic signatures can distinguish bacterial infection from other causes of fever. Implementation of this method in clinics could change the diagnostic approach for children with cancer and suspected infection. However, extracting sufficient mRNA to perform transcriptome profiling by standard methods is challenging due to the patient's low white blood cell (WBC) counts. In this prospective cohort study, we succeeded in sequencing 95% of samples from children with leukaemia and suspected infection by using a low-input protocol. This could be a solution to the issue of obtaining sufficient RNA for sequencing from patients with low white blood cell counts. Further studies are required to determine whether the captured immune gene signatures are clinically valid and thus useful to clinicians as a diagnostic tool for patients with cancer and suspected infection.
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Affiliation(s)
- Victoria Probst
- Department of Genomic Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | | | - Arman Simonyan
- Department of Genomic Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Yuliu Guo
- Department of Genomic Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Olga Østrup
- Department of Genomic Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Kia Hee Schultz Dungu
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Nadja Hawwa Vissing
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, 2100 Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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Aasa J, Tiselius E, Sinha I, Edman G, Wahlund M, Hedengren SS, Nilsson A, Berggren A. The Applicability of a 2-Transcript Signature to Identify Bacterial Infections in Children with Febrile Neutropenia. CHILDREN (BASEL, SWITZERLAND) 2023; 10:966. [PMID: 37371198 DOI: 10.3390/children10060966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/30/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023]
Abstract
Febrile neutropenia is a common complication during chemotherapy in paediatric cancer care. In this setting, clinical features and current diagnostic tests do not reliably distinguish between bacterial and viral infections. Children with cancer (n = 63) presenting with fever and neutropenia were recruited for extensive microbiological and blood RNA sampling. RNA sequencing was successful in 43 cases of febrile neutropenia. These were classified as having probable bacterial infection (n = 17), probable viral infection (n = 13) and fever of unknown origin (n = 13) based on microbiological defined infections and CRP cut-off levels. RNA expression data with focus on the 2-transcript signature (FAM89A and IFI44L), earlier shown to identify bacterial infections with high specificity and sensitivity, was implemented as a disease risk score. The median disease risk score was higher in the probable bacterial infection group, -0.695 (max 2.795; min -5.478) compared to the probable viral infection group -3.327 (max 0.218; min -7.861), which in ROC analysis corresponded to a sensitivity of 0.88 and specificity of 0.54 with an AUC of 0.80. To further characterise the immune signature, analysis of significantly expressed genes and pathways was performed and upregulation of genes associated to antibacterial responses was present in the group classified as probable bacterial infection. Our results suggest that the 2-transcript signature may have a potential use as a diagnostic tool to identify bacterial infections in immunosuppressed children with febrile neutropenia.
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Affiliation(s)
- Johannes Aasa
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Eva Tiselius
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Indranil Sinha
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Gunnar Edman
- Department of Clinical Sciences, Karolinska Institutet, 17177 Stockholm, Sweden
- Research and Development, Norrtälje Hospital, 76145 Norrtälje, Sweden
| | | | - Shanie Saghafian Hedengren
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Anna Nilsson
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
- Division of Pediatric Hematology-Oncology, Tema Barn, Astrid Lindgren Children's Hospital, 17164 Solna, Sweden
| | - Anna Berggren
- Division of Pediatric Oncology, Department of Women and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
- Research and Development, Norrtälje Hospital, 76145 Norrtälje, Sweden
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Butters C, Thursky K, Hanna DT, Cole T, Davidson A, Buttery J, Haeusler G. Adverse effects of antibiotics in children with cancer: are short-course antibiotics for febrile neutropenia part of the solution? Expert Rev Anti Infect Ther 2023; 21:267-279. [PMID: 36694289 DOI: 10.1080/14787210.2023.2171987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Febrile neutropenia is a common complication experienced by children with cancer or those undergoing hematopoietic stem cell transplantation. Repeated episodes of febrile neutropenia result in cumulative exposure to broad-spectrum antibiotics with potential for a range of serious adverse effects. Short-course antibiotics, even in patients with high-risk febrile neutropenia, may offer a solution. AREAS COVERED This review addresses the known broad effects of antibiotics, highlights developments in understanding the relationship between cancer, antibiotics, and the gut microbiome, and discusses emerging evidence regarding long-term adverse antibiotic effects. The authors consider available evidence to guide the duration of empiric antibiotics in pediatric febrile neutropenia and directions for future research. EXPERT OPINION Broad-spectrum antibiotics are associated with antimicrobial resistance, Clostridioides difficile infection, invasive candidiasis, significant disturbance of the gut microbiome and may seriously impact outcomes in children with cancer or undergoing allogenic hematopoietic stem cell transplant. Short-course empiric antibiotics are likely safe in most children with febrile neutropenia and present a valuable opportunity to reduce the risks of antibiotic exposure.
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Affiliation(s)
- Coen Butters
- Department of General Paediatrics and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Diane T Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Theresa Cole
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Andrew Davidson
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Anaesthesia, Royal Children's Hospital, Parkville, Australia.,Department of Critical Care, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, Australia
| | - Jim Buttery
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Centre for Health Analytics, Melbourne Children's Campus, Parkville, Australia.,Health Informatics Group and SAEFVIC, Murdoch Children's Research Institute, Parkville, Australia
| | - Gabrielle Haeusler
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia
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Teh BW. The long and short of antibiotic management for neutropenic fever in patients with haematological malignancy. Lancet Haematol 2022; 9:e548-e549. [PMID: 35691327 DOI: 10.1016/s2352-3026(22)00179-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
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