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Lai T, Yeo CY, Rockliff B, Stokes M, Kim HY, Marais BJ, McLachlan AJ, Alffenaar JWC. Therapeutic drug monitoring of liposomal amphotericin B in children. Are we there yet? A systematic review. J Antimicrob Chemother 2024; 79:703-711. [PMID: 38252921 PMCID: PMC10984953 DOI: 10.1093/jac/dkae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) is a tool that supports personalized dosing, but its role for liposomal amphotericin B (L-amb) is unclear. This systematic review assessed the evidence for L-amb TDM in children. OBJECTIVES To evaluate the concentration-efficacy relationship, concentration-toxicity relationship and pharmacokinetic/pharmacodynamic (PK/PD) variability of L-amb in children. METHODS We systematically reviewed PubMed and Embase databases following PRISMA guidelines. Eligible studies included L-amb PK/PD studies in children aged 0-18 years. Review articles, case series of RESULTS In total, 4220 studies were screened; 6 were included, presenting data on 195 children. Invasive candidiasis and aspergillosis were the two most common infections treated with L-amb. Studies showed significant PK variability due to age (mean age ranged from 14 days to 17 years), body weight, non-linear PK and changes in the volume of distribution. Limited evidence supported a peak concentration/MIC (Cmax/MIC) of 25-50 for optimal efficacy and an AUC24 of >600 mg·h/L for nephrotoxicity. L-amb doses of 2.5-10 mg/kg/day were reported to achieve Cmax/MIC > 25 using an MIC of 1 mg/L. CONCLUSIONS While significant PK variability was observed in children, evidence to support routine L-amb TDM was limited. Further studies on efficacy and toxicity benefits are required before routine TDM of L-amb can be recommended.
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Affiliation(s)
- Tony Lai
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Chin-Yen Yeo
- Pharmacy Department, Concord Hospital, Sydney, Australia
| | - Bradley Rockliff
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Michael Stokes
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
| | - Ben J Marais
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
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Groll AH, Körholz K, Holterhus M, Lehrnbecher T. New and emerging options for management of invasive fungal diseases in paediatric patients. Mycoses 2024; 67:e13654. [PMID: 37789721 DOI: 10.1111/myc.13654] [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: 07/10/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 10/05/2023]
Abstract
Invasive fungal diseases (IFDs) play an important role in the supportive care of paediatric patients with acute leukaemia and those undergoing allogeneic haematopoietic cell transplantation, and they are associated with significantly decreased overall survival rates in affected individuals. Relative to adults, children and adolescents are distinct in terms of host biology, predisposing conditions, presentation and epidemiology of fungal diseases, and in the pharmacology of antifungal agents. The paediatric development of antifungal agents has moved forward in a coordinated manner, and major advances have been made regarding concepts and recommendations for the prevention and treatment of IFDs. However, antifungal therapy is increasingly complex, and a solid knowledge of the available options is needed more than ever for successful management. This narrative review provides a summary of the paediatric development of agents that have been recently approved (anidulafungin, posaconazole) or are in advanced stages of development (isavuconazole). It also reviews the emerging evidence for the efficacy of echinocandins for prophylaxis of invasive aspergillosis, presents new data on alternative dosing regimens of echinocandins and voriconazole, and provides a brief overview of new antifungal agents in clinical development that are expected to be developed for paediatric patients.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Katharina Körholz
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Malcolm Holterhus
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt, Germany
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Zawitkowska J, Drabko K, Lejman M, Kowalczyk A, Czyżewski K, Dziedzic M, Jaremek K, Zalas-Więcek P, Szmydki-Baran A, Hutnik Ł, Czogała W, Balwierz W, Żak I, Salamonowicz-Bodzioch M, Kazanowska B, Wróbel G, Frączkiewicz J, Kałwak K, Tomaszewska R, Szczepański T, Zając-Spychała O, Wachowiak J, Płonowski M, Krawczuk-Rybak M, Królak A, Ociepa T, Urasiński T, Pierlejewski F, Młynarski W, Urbańska-Rakus J, Machnik K, Pająk S, Badowska W, Brzeski T, Mycko K, Mańko-Glińska H, Urbanek-Dądela A, Karolczyk G, Mizia-Malarz A, Stolpa W, Skowron-Kandzia K, Musiał J, Chaber R, Irga-Jaworska N, Bień E, Styczyński J. Incidence of bacterial and fungal infections in Polish pediatric patients with acute lymphoblastic leukemia during the pandemic. Sci Rep 2023; 13:22619. [PMID: 38114744 PMCID: PMC10730514 DOI: 10.1038/s41598-023-50093-5] [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: 09/10/2023] [Accepted: 12/15/2023] [Indexed: 12/21/2023] Open
Abstract
The most common complications related to the treatment of childhood acute lymphoblastic leukemia (ALL) are infections. The aim of the study was to analyze the incidence and mortality rates among pediatric patients with ALL who were treated in 17 Polish pediatric hematology centers in 2020-2021 during the pandemic. Additionally, we compared these results with those of our previous study, which we conducted in the years 2012-2017. The retrospective analysis included 460 patients aged 1-18 years with newly diagnosed ALL. In our study, 361/460 (78.5%) children were reported to have microbiologically documented bacterial infections during chemotherapy. Ten patients (2.8%) died due to sepsis. Fungal infections were reported in 99 children (21.5%), of whom five (5.1%) died due to the infection. We especially observed an increase in bacterial infections during the pandemic period compared to the previous study. The directions of our actions should be to consider antibiotic prophylaxis, shorten the duration of hospitalization, and educate parents and medical staff about complications (mainly infections) during anticancer therapy. It is necessary to continue clinical studies evaluating infection prophylaxis to improve outcomes in childhood ALL patients.
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Affiliation(s)
- Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland.
| | - Katarzyna Drabko
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, Lublin, Poland
| | - Adrian Kowalczyk
- Student Scientific Society of Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Czyżewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Kamila Jaremek
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Patrycja Zalas-Więcek
- Department of Microbiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Anna Szmydki-Baran
- Department of Hematology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Hutnik
- Department of Hematology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Czogała
- Department of Pediatric Oncology and Hematology, Intitute of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Intitute of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Iwona Żak
- Department of Microbiology, University Children's Hospital, Jagiellonian University Medical College, Kraków, Poland
| | | | - Bernarda Kazanowska
- Department of Pediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Grażyna Wróbel
- Department of Pediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Jowita Frączkiewicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Renata Tomaszewska
- Department of Pediatrics, Hematology and Oncology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Szczepański
- Department of Pediatrics, Hematology and Oncology, Medical University of Silesia, Katowice, Poland
| | - Olga Zając-Spychała
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Płonowski
- Department of Pediatric Oncology, Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology, Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Aleksandra Królak
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Ociepa
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Urasiński
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Filip Pierlejewski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | | | - Katarzyna Machnik
- Unit of Pediatric Hematology and Oncology, City Hospital, Chorzow, Poland
| | - Sonia Pająk
- Unit of Pediatric Hematology and Oncology, City Hospital, Chorzow, Poland
| | - Wanda Badowska
- Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Tomasz Brzeski
- Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Katarzyna Mycko
- Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Hanna Mańko-Glińska
- Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Agnieszka Urbanek-Dądela
- Department of Pediatric Oncology and Hematology, Collegium Medium of Jan Kochanowski University in Kielce, Kielce, Poland
| | - Grażyna Karolczyk
- Department of Pediatric Oncology and Hematology, Collegium Medium of Jan Kochanowski University in Kielce, Kielce, Poland
| | - Agnieszka Mizia-Malarz
- Department of Oncology, Hematology and Chemotherapy, Upper Silesia Children's Care Health, Medical University of Silesia, Katowice, Poland
| | - Weronika Stolpa
- Department of Oncology, Hematology and Chemotherapy, Upper Silesia Children's Care Health, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Skowron-Kandzia
- Department of Oncology, Hematology and Chemotherapy, Upper Silesia Children's Care Health, Medical University of Silesia, Katowice, Poland
| | - Jakub Musiał
- Clinic of Pediatric Oncology and Hematology, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
| | - Radosław Chaber
- Clinic of Pediatric Oncology and Hematology, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology, Oncology and Endocrinology, Medical University of Gdansk, Gdańsk, Poland
| | - Ewa Bień
- Department of Pediatrics, Hematology, Oncology and Endocrinology, Medical University of Gdansk, Gdańsk, Poland
| | - Jan Styczyński
- Student Scientific Society of Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
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刘 晓, 唐 雪, 王 璐, 王 缨, 刘 仕, 周 桂, 李 统, 麦 惠. [Blinatumomab as bridging therapy in two children with B-cell acute lymphoblastic leukemia complicated by invasive fungal disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1282-1286. [PMID: 38112148 PMCID: PMC10731972 DOI: 10.7499/j.issn.1008-8830.2306142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/18/2023] [Indexed: 12/20/2023]
Abstract
This article reports two cases of children with B-cell acute lymphoblastic leukemia (B-ALL) complicated by invasive fungal disease (IFD) who received bridging treatment using blinatumomab. Case 1 was a 4-month-old female infant who experienced recurrent high fever and limb weakness during chemotherapy. Blood culture was negative, and next-generation sequencing (NGS) of peripheral blood, bronchoalveolar lavage fluid, and cerebrospinal fluid were all negative. Chest CT and cranial MRI revealed obvious infection foci. Case 2 was a 2-year-old male patient who experienced recurrent high fever with multiple inflammatory masses during chemotherapy. Candida tropicalis was detected in peripheral blood and abscess fluid using NGS, while blood culture and imaging examinations showed no obvious abnormalities. After antifungal and blinatumomab therapy, both cases showed significant improvement in symptoms, signs, and imaging, and B-ALL remained in continuous remission. The report indicates that bridging treatment with blinatumomab in children with B-ALL complicated by IFD can rebuild the immune system and control the underlying disease in the presence of immunosuppression and severe fungal infection.
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Tverdek F, Escobar ZK, Liu C, Jain R, Lindsay J. Antimicrobials in patients with hematologic malignancies and recipients of hematopoietic cell transplantation and other cellular therapies. Transpl Infect Dis 2023; 25 Suppl 1:e14129. [PMID: 37594221 DOI: 10.1111/tid.14129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/28/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Appropriate use of antimicrobials for hematologic malignancy, hematopoietic stem cell transplant recipients, and other cellular therapies is vital, with infection causing significant morbidity and mortality in this unique population of immunocompromised hosts. However, often in this population the choice and management of antimicrobial therapy is complex. When selecting an antimicrobial agent, key considerations include the need for dose adjustments due to renal or hepatic impairment, managing drug interactions, the potential for additive drug toxicity among those receiving polypharmacy and therapeutic drug monitoring. Other factors include leveraging pharmacodynamic principles to enable optimization of directed therapy against challenging pathogens, as well as judicious use of antimicrobials to limit drug resistance and adverse drug reactions. SUMMARY This review summarizes the clinical considerations for commonly used antimicrobials in this setting, including antibacterial, antiviral, and antifungal agents.
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Affiliation(s)
- Frank Tverdek
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Zahra Kassamali Escobar
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Rupali Jain
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Julian Lindsay
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- National Centre for Infection in Cancer and Transplantation (NCICT), Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Yeoh DK, McMullan BJ, Clark JE, Slavin MA, Haeusler GM, Blyth CC. The Challenge of Diagnosing Invasive Pulmonary Aspergillosis in Children: A Review of Existing and Emerging Tools. Mycopathologia 2023; 188:731-743. [PMID: 37040020 PMCID: PMC10564821 DOI: 10.1007/s11046-023-00714-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/07/2023] [Indexed: 04/12/2023]
Abstract
Invasive pulmonary aspergillosis remains a major cause of morbidity and mortality for immunocompromised children, particularly for patients with acute leukaemia and those undergoing haematopoietic stem cell transplantation. Timely diagnosis, using a combination of computed tomography (CT) imaging and microbiological testing, is key to improve prognosis, yet there are inherent challenges in this process. For CT imaging, changes in children are generally less specific than those reported in adults and recent data are limited. Respiratory sampling by either bronchoalveolar lavage or lung biopsy is recommended but is not always feasible in children, and serum biomarkers, including galactomannan, have important limitations. In this review we summarise the current paediatric data on available diagnostic tests for IPA and highlight key emerging diagnostic modalities with potential for future use.
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Affiliation(s)
- Daniel K Yeoh
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Brendan J McMullan
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women's and Children's Health, UNSW, Sydney, NSW, Australia
| | - Julia E Clark
- Infection Management Service, Queensland Children's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Children's Health Queensland Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Monica A Slavin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Gabrielle M Haeusler
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Royal Children's Hospital, Parkville, VIC, Australia
- The Paediatric Integrated Cancer Service, Melbourne, VIC, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
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Papan C, Reifenrath K, Last K, Attarbaschi A, Graf N, Groll AH, Hübner J, Laws HJ, Lehrnbecher T, Liese JG, Martin L, Tenenbaum T, Vieth S, von Both U, Wagenpfeil G, Weichert S, Hufnagel M, Simon A, Baier J, Balzer S, Behr Ü, Bernbeck B, Beutel K, Blattmann C, Bochennek K, Cario H, Eggert A, Ehlert K, Göpner S, Kontny U, Körholz D, Kramm C, Lauten M, Lessel L, Linderkamp C, Lobitz S, Maas V, Misgeld R, Mücke U, Neubert J, Nonnenmacher L, Queudeville M, Redlich A, Rodehüser M, Schober S, Siepermann M, Simon T, Souliman H, Stiefel M, Wiegering V, Winkler B. Antimicrobial use in pediatric oncology and hematology in Germany and Austria, 2020/2021: a cross-sectional, multi-center point-prevalence study with a multi-step qualitative adjudication process. Lancet Reg Health Eur 2023; 28:100599. [PMID: 37180743 PMCID: PMC10173264 DOI: 10.1016/j.lanepe.2023.100599] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
Background Due to the high risk of severe infection among pediatric hematology and oncology patients, antimicrobial use is particularly high. With our study, we quantitatively and qualitatively evaluated, based on institutional standards and national guidelines, antimicrobial usage by employing a point-prevalence survey with a multi-step, expert panel approach. We analyzed reasons for inappropriate antimicrobial usage. Methods This cross-sectional study was conducted at 30 pediatric hematology and oncology centers in 2020 and 2021. Centers affiliated to the German Society for Pediatric Oncology and Hematology were invited to join, and an existing institutional standard was a prerequisite to participate. We included hematologic/oncologic inpatients under 19 years old, who had a systemic antimicrobial treatment on the day of the point prevalence survey. In addition to a one-day, point-prevalence survey, external experts individually assessed the appropriateness of each therapy. This step was followed by an expert panel adjudication based upon the participating centers' institutional standards, as well as upon national guidelines. We analyzed antimicrobial prevalence rate, along with the rate of appropriate, inappropriate, and indeterminate antimicrobial therapies with regard to institutional and national guidelines. We compared the results of academic and non-academic centers, and performed a multinomial logistic regression using center- and patient-related data to identify variables that predict inappropriate therapy. Findings At the time of the study, a total of 342 patients were hospitalized at 30 hospitals, of whom 320 were included for the calculation of the antimicrobial prevalence rate. The overall antimicrobial prevalence rate was 44.4% (142/320; range 11.1-78.6%) with a median antimicrobial prevalence rate per center of 44.5% (95% confidence interval [CI] 35.9-49.9). Antimicrobial prevalence rate was significantly higher (p < 0.001) at academic centers (median 50.0%; 95% CI 41.2-55.2) compared to non-academic centers (median 20.0%; 95% CI 11.0-32.4). After expert panel adjudication, 33.8% (48/142) of all therapies were labelled inappropriate based upon institutional standards, with a higher rate (47.9% [68/142]) when national guidelines were taken into consideration. The most frequent reasons for inappropriate therapy were incorrect dosage (26.2% [37/141]) and (de-)escalation/spectrum-related errors (20.6% [29/141]). Multinomial, logistic regression yielded the number of antimicrobial drugs (odds ratio, OR, 3.13, 95% CI 1.76-5.54, p < 0.001), the diagnosis febrile neutropenia (OR 0.18, 95% CI 0.06-0.51, p = 0.0015), and an existing pediatric antimicrobial stewardship program (OR 0.35, 95% CI 0.15-0.84, p = 0.019) as predictors of inappropriate therapy. Our analysis revealed no evidence of a difference between academic and non-academic centers regarding appropriate usage. Interpretation Our study revealed there to be high levels of antimicrobial usage at German and Austrian pediatric oncology and hematology centers with a significant higher number at academic centers. Incorrect dosing was shown to be the most frequent reason for inappropriate usage. Diagnosis of febrile neutropenia and antimicrobial stewardship programs were associated with a lower likelihood of inappropriate therapy. These findings suggest the importance of febrile neutropenia guidelines and guidelines compliance, as well as the need for regular antibiotic stewardship counselling at pediatric oncology and hematology centers. Funding European Society of Clinical Microbiology and Infectious Diseases, Deutsche Gesellschaft für Pädiatrische Infektiologie, Deutsche Gesellschaft für Krankenhaushygiene, Stiftung Kreissparkasse Saarbrücken.
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8
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Yeoh DK, Blyth CC, Kotecha RS. Blinatumomab as bridging therapy in paediatric B-cell acute lymphoblastic leukaemia complicated by invasive fungal disease. Br J Haematol 2022; 198:887-892. [PMID: 35727917 PMCID: PMC9539952 DOI: 10.1111/bjh.18314] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
Invasive fungal disease (IFD) remains a challenging complication of treatment for paediatric acute leukaemia. Consensus fungal treatment guidelines recommend withholding chemotherapy to facilitate immune recovery in this setting, yet prolonged delays in leukaemia therapy increase risk of relapse. Blinatumomab, a bispecific T‐cell engager targeting cells expressing CD19, has shown promise for treatment of relapsed/refractory B‐cell acute lymphoblastic leukaemia (B‐ALL) and is associated with reduced toxicity compared to conventional chemotherapy. With close monitoring of minimal residual disease, we demonstrate that children with B‐ALL can receive repeated cycles of bridging blinatumomab whilst conventional chemotherapy is withheld during treatment and recovery from IFD.
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Affiliation(s)
- Daniel K Yeoh
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Rishi S Kotecha
- Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, Western Australia, Australia.,Curtin Medical School, Curtin University, Perth, Western Australia, Australia.,Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
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