Peripheral vs. central blood cultures in patients admitted to a pediatric oncology ward

Comparison Between Peripheral and Central Blood Cultures in Pediatric Oncology Patients With Blood Stream Infections

BACKGROUND

Current guidelines for fever in children with cancer recommend obtaining blood cultures from all lumens of the central venous catheter (CVC) and to consider a concurrent peripheral blood culture. We assessed the characteristics of blood stream infections (BSI) in oncology children and compared central and peripheral pathogen growth.

METHODS

A prospective, computerized surveillance of BSI in children treated at the oncology unit between May 2014 and July 2020. The growth of the same organism within a month was considered a single episode, ≥2 organisms in the same culture were defined as different episodes. Only children with concomitant cultures, drawn at presentation before initiation of antibiotics were included in the comparison between CVC and peripheral cultures.

RESULTS

A total of 139 episodes in 81 children (with implanted Port-A-catheters) were considered true BSI. Of the 94/139 (67.6%) cases where a central and peripheral culture were concomitantly obtained, 52/94 (55.3%) had positive central/peripheral cultures that grew the same organism, 31/94 (33.0%) had positive central cultures only, and 11/94 (11.7%) had positive peripheral cultures only. In 3/94 cases, the organisms that grew from the CVC were not identical to those from the peripheral site. Four of 52 (7.7%) of the same positive central/peripheral pathogens had different susceptibility testing results. Higher CVC removal rates were observed when both peripheral and CVC cultures were positive ( P =0.044).

CONCLUSIONS

Overall, 11.7% of BSI episodes were identified only by peripheral culture and 7.7% of paired organisms did not share the same susceptibility test results which emphasizes the importance of a peripheral culture in managing fever in oncology children.

Sampling Multiple Catheter Lumens to Improve Detection of Bloodstream Infection in Pediatric Oncology Patients

Current guidelines recommend sampling each central-access lumen during the initial evaluation of febrile pediatric oncology patients. We investigated this recommendation's validity at centers implementing a diagnostic stewardship program to reduce blood cultures in critically ill children. Among 146 oncology patients admitted to the intensive care unit, there were 34 eligible blood culture-sets. Eleven (34%) sets yielded discordant results, most commonly cultivating a likely pathogen from one lumen and no growth from another. As hospitals move toward reducing testing overuse, these results emphasize the continued importance of culturing each central-access lumen to optimize the detection of bacteremia in the initial evaluation of critically ill pediatric oncology patients.

Guidance Statement for the Management of Febrile Neutropenia in Pediatric Patients Receiving Cancer-Directed Therapy in Central America and the Caribbean

PURPOSE

Our objective was to provide regionally appropriate, resource-conscious recommendations for the diagnosis and treatment of pediatric patients with febrile neutropenia.

METHODS

A multinational panel of Central American and Caribbean clinicians who deliver pediatric oncology care prioritized clinically important questions and then used the Grading of Recommendations Assessment, Development and Evaluation methodology to provide recommendations on the selected topics.

RESULTS

Twenty-two questions and 2 definitions were included in the guideline, which was intended to establish minimum care standards for pediatric patients treated in regional centers. Of all the included studies, 6.9% were conducted in low- and middle-income countries, and no studies were performed in countries represented on the panel.

CONCLUSION

The panel made recommendations on the basis of existing evidence but identified important gaps in knowledge from the region and from resource-limited settings that may affect the clinical applicability of these recommendations. These deficiencies suggest a research agenda that will enable future guidelines to be more responsive to the local context.

A clinical approach to non-neutropenic fever in children with cancer

BACKGROUND

There are a limited number of studies that address non-neutropenic fever episodes in children with cancer, and no standard approach exists.

METHOD

We opt to retrospectively analyze the efficacy of the current clinical approach for management of non-neutropenic fever episodes and the associated risk factors among children with cancer at the Princess Noorah Oncology Center from May 2016 through December 2017.

RESULTS

A total of 480 non-neutropenic fever episodes were identified in 131 children, of which 62 episodes were triaged as high-risk non-neutropenic fever and 418 as low-risk non-neutropenic fever. Of those 480 non-neutropenic fever, 361 episodes (75.2%) were associated with the presence of central venous catheters. The overall failure rate of ceftriaxone mono-therapy was observed in 75.6% (11.7% in high-risk non-neutropenic fever with a mean C-reactive protein level of 21.1 (±23.2) mmol/L and 63.9% in low-risk non-neutropenic fever with a mean C-reactive protein level of 17.6 (±53.9) mmol/L). The overall bacteremia rate was 14.4%. The type of organisms isolated was mainly high-risk organisms in 59 non-neutropenic fever episodes (85.5%), OR 1.78 (95% CI: 0.45-7.04) p = 0.41. Of note, all bacteremia were associated with the presence of central venous catheter (100%). Of all the examined risk factors of outpatient treatment failure in low-risk non-neutropenic fever, only prolonged fever of more than three days were significantly associated with bacteremia OR 8.107 [95% CI: 1.744-37.691], p = 0.008. Noteworthy is that almost 43% of non-neutropenic fever episodes were associated with respiratory symptoms. This study provides a baseline for future prospective research assessing the pattern of non-neutropenic fever by focusing on associated risk factors.

Guideline for the Management of Fever and Neutropenia in Children With Cancer and Hematopoietic Stem-Cell Transplantation Recipients: 2017 Update

Purpose To update a clinical practice guideline (CPG) for the empirical management of fever and neutropenia (FN) in children with cancer and hematopoietic stem-cell transplantation recipients. Methods The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group of experts in pediatric oncology and infectious diseases that includes a patient advocate. For questions of risk stratification and evaluation, we updated systematic reviews of observational studies. For questions of therapy, we conducted a systematic review of randomized trials of any intervention applied for the empirical management of pediatric FN. The Grading of Recommendation Assessment, Development and Evaluation approach was used to make strong or weak recommendations and to classify levels of evidence as high, moderate, low, or very low. Results Recommendations related to initial presentation, ongoing management, and empirical antifungal therapy of pediatric FN were reviewed; the most substantial changes were related to empirical antifungal therapy. Key differences from our 2012 FN CPG included the listing of a fourth-generation cephalosporin for empirical therapy in high-risk FN, refinement of risk stratification to define patients with high-risk invasive fungal disease (IFD), changes in recommended biomarkers and radiologic investigations for the evaluation of IFD in prolonged FN, and a weak recommendation to withhold empirical antifungal therapy in IFD low-risk patients with prolonged FN. Conclusion Changes to the updated FN CPG recommendations will likely influence the care of pediatric patients with cancer and those undergoing hematopoietic stem-cell transplantation. Future work should focus on closing research gaps and on identifying ways to facilitate implementation and adaptation.

Neutropenia in the Febrile Child

Fever in the pediatric population is a common chief complaint presenting to the emergency department and may be one of the first indications of a life-threatening infection, especially in patients with neutropenia. Given that pediatric patients with febrile neutropenia frequently present to emergency departments for emergent care, it is critical for emergency medicine physicians and pediatricians and family physicians working in the emergency department to know the key aspects of the clinical approach to these patients. This review of the clinical evaluation and treatment of the pediatric patient presenting with fever and confirmed or suspected neutropenia will provide health care providers with the necessary tools to effectively care for this patient population.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.

Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks.

Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).

Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia

Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.

Importance of blood cultures from peripheral veins in pediatric patients with cancer and a central venous line

BACKGROUND

When an infection is suspected in a child with cancer and a central venous line (CVL), cultures are often only obtained from the CVL and not from a peripheral vein (PV). This study was undertaken to evaluate the importance of concomitant blood cultures from the CVL and a PV.

PROCEDURE

Clinical data and the results of all cultures taken concomitantly from the CVL and a PV were registered prospectively in children admitted with fever from April 2008 to December 2012 at the Department of Pediatrics at Aarhus University Hospital Skejby.

RESULTS

During the study period 654 paired cultures obtained from the CVL and from a PV within two hour of each other were included. A true bloodstream infection (BSI) was registered in 112 episodes. In 20 (17%) out of 112, true BSI growth of a microorganism was detected only in the culture from a PV including seven cases of Escherichia coli and three cases of Staphylococcus aureus. In 52 episodes the same microorganism was cultured from both the CVL and a PV. Twenty-four of these episodes were classified as catheter-related bloodstream infections (CRBSI) using differential time to positivity. In total, 64 (57%) of all true BSI were defined as CRBSI.

CONCLUSIONS

Blood cultures should be obtained from a PV in addition to cultures from CVL at the onset of fever in pediatric patients with cancer in order to maximize the findings of true BSIs. The frequency of CRBSI may be over-estimated if blood cultures are drawn from CVL only.

Management of febrile neutropenia in the era of bacterial resistance

Managing cancer patients with fever and neutropenia must be considered as a medical emergency since any delay in initiating appropriate empirical antibacterial therapy may result in high rates of mortality and morbidity. Emerging antibacterial resistance in bacterial pathogens infecting febrile neutropenic patients complicates management, and choosing the type of empirical antimicrobial therapy has become a challenge. To further complicate the decision process, not all neutropenic patients are in same category of susceptibility to develop severe infection. While low-risk patients may be treated with oral antibiotics in the outpatient setting, high-risk patients usually need to be admitted to hospital and receive parenteral broad-spectrum antibiotics until the neutrophil levels recover. These strategies have recently been addressed in two international guidelines from the Infectious Diseases Society of America (IDSA) and the European Conference on Infections in Leukaemia (ECIL). This review gives a brief overview of current antimicrobial resistance problems and their effects in febrile neutropenic cancer patients by summarizing the suggestions from the IDSA and ECIL guidelines.

How many sources should be cultured for the diagnosis of a blood stream infection in children with cancer?

Blood stream infection (BSI) in a child with cancer is a life-threatening condition while blood cultures (BCs) play a crucial role for the diagnosis. The current practice of obtaining a BC from all sources--peripheral vein, central venous catheter (CVC), all lumens--is controversial and therefore in this study, our aim was to evaluate the utility of obtaining BCs from all these available sources. A retrospective study of BC sets obtained from all newly diagnosed patients with malignancy was conducted. A total number of 633 BC sets from 123 boys and 88 girls (median age: 5 5/12 years) were evaluated during infection episodes from January 1, 2005, to August 31, 2010. Among these cases, 134 were classified as true BSI (21%), 468 as non-BSI, and 31 as false-positive. In 64 cases, the results from peripheral and CVC sources were discordant: 57 catheter positive-peripheral negative and seven catheter negative-peripheral positive. Consequently, seven out of 134 true BSIs (5.2%) would not have been identified if only a BC from a CVC had been obtained. Moreover, if no BCs from all lumens had been obtained we would have missed up to 25% of true-positive BSIs. In the same way, if BCs from all sources had not been drawn we would not have detected up to 52% of true-positive BSIs.

CONCLUSION

Obtaining BCs during an infection episode from all sources in a child with cancer is still mandatory.

Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation

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.

Central venous catheter-associated bloodstream infections

BACKGROUND

To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008.

PATIENTS AND METHODS

The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome.

RESULTS

There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded.

CONCLUSIONS

CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america

This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care-associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.

Executive Summary: Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America

This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia.

Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving.

What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens.

Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care–associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.

Performing allogeneic and autologous hematopoietic SCT in the outpatient setting: effects on infectious complications and early transplant outcomes

This retrospective single-center study compared the incidence, spectrum and effect of infections in 1045 consecutive allogeneic (allo) and autologous (auto) hematopoietic SCT (HSCT) performed between 1995 and 2006 in the inpatient (IP) or outpatient (OP) setting. We analyzed 374 allo-HSCT (196 IP and 178 OP) and 671 auto-HSCT (163 IP and 508 OP). The incidence of infection was lower both in auto-OP (25% OP vs 33% IP, P=0.042) and allo-OP cohorts (42.7% OP vs 55.6% IP, P=0.012). The mean number of infections per transplant was lower in both auto-OP (0.39 OP vs 0.57 IP, P=0.05) and in allo-OP cohorts (0.78 OP vs 1.09 IP, P=0.018). The 100-day non-relapse mortality (NRM) for OP auto-HSCT was 4.72% and for IP 3.95% (P=0.68). The 100-day NRM for OP allo-HSCT was lower at 14.1% than it was for IP at 22.6% (P=0.041). Time to onset of first infection and spectrum of infections was similar in all groups. We conclude that performing allo- and auto-HSCT in the OP setting results in short-term outcomes, including infections complications that are comparable to the standard IP setting.

Port-A-Cath Insertions in Acute Leukaemia and Childhood Malignancies

OBJECTIVE

This retrospective case series sought to determine the incidence and profile of catheter-related complications associated with Port-A-Cath insertions in paediatric cancer patients, as well as predictive factors for infection-related port removals.

METHODS

Between January 2002 and December 2004, 175 consecutive Port-A-Cath insertions were followed for a total of 75,000 days (median, 407; range, 6-1,074). Incidence of catheter-related bloodstream infections (CRBSIs), other complications and CRBSI-related port removals were analysed for cases with acute leukaemia versus other malignancies.

RESULTS

A total of 33 CRBSIs were encountered in 26 cases (18.9%), an infection rate of 0.44 episodes per 1,000 catheter days. While mean preoperative platelet count was 125.34 x 10(9)/L in children with acute leukaemia and 392.11 x 10(9)/L in those with other malignancies (p < 0.01), the incidence of all complications were similar between both subgroups. Staphylococcus epidermidis (23.1%) and Klebsiella spp. (19.2%) were most commonly isolated from infected ports. Median patient age and duration of implantation in CRBSI-related port removals was 1.5 years and 111 days respectively, and 10.0 years and 414 days respectively in CRBSIs without port removal.

CONCLUSION

Minimal complications are associated with Port-A-Cath insertions, even in thrombocytopaenic leukaemic patients. The dominance of Gram-negative organisms in CRBSIs parallels the changing trend of nosocomial infectious agents involved in catheter-related infections.

Diagnosis and treatment of catheter-related infections in paediatric oncology: an update

Otherwise unexplained clinical signs of infection in patients with long-term tunnelled or totally implanted central venous access devices (CVADs) are suspected to be CVAD-associated. Diagnostic methods include catheter swabs, blood cultures and cultures of the catheter tip or port reservoir. In the case of a suspected CVAD-related bloodstream infection in paediatric oncology patients, in-situ treatment without prompt removal of the device can be attempted. Removal of the CVAD should be considered if bacteraemia persists or relapses > or = 72 h after the initiation of (in-vitro effective) antibacterial therapy administered through the line. Timely removal of the device is also recommended if the patient suffers from a complicated infection, or if Staphylococcus aureus, Pseudomonas aeruginosa, multiresistant Acinetobacter baumannii or Candida spp. are isolated from blood cultures. Duration of therapy depends on the immunological recovery of the patient, the pathogen isolated and the presence of related complications, such as thrombosis, pneumonia, endocarditis and osteomyelitis. Antibiotic lock techniques in addition to systemic treatment are beneficial for Gram-positive infections. Although prospectively controlled studies are lacking, the concomitant use of urokinase locks and taurolidine secondary prophylaxis seem to favour catheter salvage.

Port-A-Cath infections in children with cancer

Implanted subcutaneous (s.c.) central venous port accesses including Port-A-Cath (PAC) facilitate the administration of chemotherapy or blood products and are frequently used in children with cancer. The incidence of PAC-related infections was determined in 155 consecutive paediatric cancer patients with PAC followed for a total of 134,773 days (median, 738; range, 25-2080). Overall, 48 bloodstream infections occurred in 26 patients. 12 (25%) of these infections and 3 local infections at the insertion site were treatment-resistant and demanded removal of the PAC. Coagulase-negative staphylococci were involved in 12 of these 15 episodes. The rate of clearly PAC-related infections in this so far largest reported series was 0.11 episodes per 1000 PAC days, one of the lowest in the literature. Although catheter-related infections demanded PAC removal in 8% of our patients, the long periods PAC were in use and their benefits argue for continued PAC use in the paediatric cancer population.

Predicting bacteremia in children with fever and chemotherapy-induced neutropenia

BACKGROUND

Fever and neutropenia are common clinical problems in pediatric oncology and frequently necessitate emergency hospitalization and immediate empiric broad spectrum antimicrobial therapy. Estimating the risk of bacteremia in fever and neutropenia is a challenge. The purpose of this study was to develop an algorithm predicting the risk of bacteremia and Gram-negative bacteremia in children and adolescents with fever and neutropenia, based on information accessible at presentation.

METHODS

We collected information available within 2 h of presentation of children with fever and neutropenia and, on outcome, from all pediatric cancer patients presenting with fever and neutropenia from 1993 through 2001 in a retrospective single center cohort study. After univariate analyses a multivariate decision tree was constructed, and its performance was evaluated by cross-validation.

RESULTS

Bacteremia was detected in 87 (24%) and Gram-negative bacteremia in 30 (8%) of 364 episodes of fever and neutropenia. At the predetermined sensitivity level, > or =95%, decision tree models reached cross-validated specificities of 37 and 43%, with negative predictive values of 96 and 99%, for bacteremia and Gram-negative bacteremia, respectively. Absence of a clinically or radiologically evident source of infection and previous episodes of fever and neutropenia were defined as two newly described factors associated with bacteremia.

CONCLUSIONS

Based on this retrospective analysis, it appears that bacteremia can be predicted with clinically useful specificity at a high level of sensitivity, using clinical information available at presentation in pediatric cancer patients with fever and neutropenia.

Evaluation and treatment of fever in the non-neutropenic child with cancer

PURPOSE

To document the current approach to the evaluation and treatment of febrile non-neutropenic children with cancer by surveying American Society of Pediatric Hematology/Oncology (ASPHO) members.

METHODS

Five hundred ninety-five ASPHO members were sent questionnaires polling their current practices in the evaluation and treatment of clinically stable, febrile (oral temperature of 38 degrees C x2, or >or=38.3 degrees C), non-neutropenic (absolute neutrophil count > 500/microL) pediatric cancer patients who have no identifiable bacterial infection. Patients were assigned to one of four groups based on the presence or absence of a central venous catheter (CVC) and no source (NS) or presumed viral source (VS) for fever.

RESULTS

Three hundred sixteen ASPHO members (53%) responded and 300 questionnaires were evaluable. If a CVC was present, respondents universally drew blood cultures (99% NS, 96% VS) from the CVC, but only one third drew peripheral blood cultures (33% NS, 29% VS). If a CVC was not present, the majority of respondents (80% NS, 61% VS) drew peripheral cultures. ASPHO members started empiric antibiotics more frequently in patients with a CVC (69% NS, 55% VS) than in patients without a CVC (33% NS, 23% VS). Most did not admit these patients to the hospital (40% CVC and NS, 33% CVC and VS, 22% no CVC and NS, 19% no CVC and VS). ASPHO members with more years of experience were more likely to obtain peripheral blood cultures if a CVC was present and to admit a patient without a CVC.

CONCLUSIONS

Nearly all respondents obtained a blood culture from the CVC in the initial assessment of the febrile, non-neutropenic patient with a CVC, but other evaluation and management practices varied considerably.

The pediatrician and medical care of the child with cancer

The child's pediatrician is an important resource for families regarding a host of issues such as infections, complications and side effects of chemotherapy, school issues, and psychosocial stressors that are common in families of children with life-threatening illness. This article provides guidance for caring for children with malignancies in the primary care setting.

Sensitivity of a blood culture drawn through a single lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients

PURPOSE

The study assessed the sensitivity of a blood culture drawn from only one lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients.

METHODS

Episodes of positive blood cultures were included if cultures were sent simultaneously from multiple lumens of a long-term, indwelling, central line and if the culture was thought to represent a true bacteremia.

RESULTS

Discordant results from cultures drawn simultaneously from different lumens occurred in 13 (32%) of 41 episodes. The estimated sensitivity of a culture drawn from a single lumen was 84%.

CONCLUSION

Drawing blood cultures from all lumens of these lines should be considered in this patient population.