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Masetti R, Bossù G, Muratore E, Leardini D, Gatti M, Di Sario R, Pea F, Esposito S. Therapeutic Drug Monitoring of Antimicrobial Drugs in Children with Cancer: A New Tool for Personalized Medicine. Paediatr Drugs 2025; 27:41-56. [PMID: 39503988 DOI: 10.1007/s40272-024-00663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 01/29/2025]
Abstract
The risk of fungal, bacterial, and viral infections is higher in children with hematological and solid malignancies, particularly during periods of profound neutropenia. Although early administration of antimicrobial agents is common, optimizing pharmacological therapy in pediatric patients with cancer is challenging because of their variable pharmacokinetics compared with adults, including differences in body mass and augmented renal clearance, as well as chemotherapy-induced organ toxicity. Therapeutic drug monitoring, which involves measuring drug concentrations in serum or plasma at specific timepoints and adjusting doses accordingly, can be applied to various medications. While standardized targets for all antimicrobial agents in children are lacking, therapeutic drug monitoring appears to be beneficial in preventing serious toxicity and addressing treatment failure or non-compliance. This narrative review aims to analyze current perspectives on therapeutic drug monitoring for antimicrobial drugs in the special population of children with hematological or oncological diseases, including those undergoing hematopoietic cell transplantation. The review provides evidence on the clinical benefits of this method and explores potential future developments in this area.
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Affiliation(s)
- Riccardo Masetti
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
| | - Gianluca Bossù
- Pietro Barilla Children's Hospital, Pediatric Clinic, University of Parma, Parma, Italy
| | - Edoardo Muratore
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Davide Leardini
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Milo Gatti
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Di Sario
- Pietro Barilla Children's Hospital, Pediatric Clinic, University of Parma, Parma, Italy
| | - Federico Pea
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Susanna Esposito
- Pietro Barilla Children's Hospital, Pediatric Clinic, University of Parma, Parma, Italy
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Impact of genetic polymorphisms determining leukocyte/neutrophil count on chemotherapy toxicity. THE PHARMACOGENOMICS JOURNAL 2017; 18:270-274. [DOI: 10.1038/tpj.2017.16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022]
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Zhou Y, Cui Y, Wang H, Wang F, Lu C, Shen Y. Developing a tool for nurses to assess risk of infection in pediatric oncology patients in China: a modified Delphi study. J Biomed Res 2016; 30:386-392. [PMID: 27845302 PMCID: PMC5044711 DOI: 10.7555/jbr.30.20160014] [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: 01/28/2016] [Revised: 02/24/2016] [Accepted: 05/24/2016] [Indexed: 11/23/2022] Open
Abstract
Infections are identified as the most common preventable cause of death in pediatric oncology patients. Assessing and stratifying risk of infections are essential to prevent infection in these patients. To date, no tool can fulfill this demand in China. This study aimed to develop a nursing work-based and Chinese-specific tool for pediatric nurses to assess risk of infection in oncology patients. This research was a modified Delphi study. Based on a literature review, a 37-item questionnaire rating on a 0–5 scale was developed. Twenty-four experts from 8 hospitals in 6 provinces of China were consulted for three rounds. Consensus for each item in the first round was defined as: the rating mean was > 3 and the coefficient of variation (CV) was < 0.5. Consensus for each item in the second round was defined as CV < 0.3. Consensus among experts was defined as: P value of Kendall's coefficient of concordance (W) < 0.05. After three rounds of consultation, a two-part tool was developed: the Immune Status Scale (ISS) and the Checklist of Risk Factors of Infection (CRFI). There were 5 items in the ISS and 14 in the CRFI. Based on the ISS score, nurses could stratify children into the low-risk and high-risk groups. For high-risk children, nurses should screen risk factors of infection every day by the CRFI, and twice weekly for low-risk children. Further study is needed to verify this tool's efficacy.
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Affiliation(s)
- Yufeng Zhou
- Department of Basic and Community Nursing, School of Nursing, Nanjing Medical University, Nanjing, JIangsu 211166, China
| | - Yan Cui
- Department of Basic and Community Nursing, School of Nursing, Nanjing Medical University, Nanjing, JIangsu 211166, China;
| | - Hong Wang
- Department of Respiratory, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China;
| | - Fang Wang
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Chao Lu
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yan Shen
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Green AL, Yi J, Bezler N, Pikman Y, Tubman VN, Obeng EA, O’Neil T, Mersereau R, Morrissey L, Billett AL. A Prospective Cohort Quality Improvement Study to Reduce the Time to Antibiotics for New Fever in Neutropenic Pediatric Oncology Inpatients. Pediatr Blood Cancer 2016; 63:112-7. [PMID: 26292080 PMCID: PMC11287932 DOI: 10.1002/pbc.25712] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 07/15/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fever and neutropenia (F&N) is a pediatric oncology emergency due to the risk of disseminated infection. Quality improvement (QI) efforts to improve time to antibiotics for F&N in the emergency department have been documented, but the issue has not been studied in the established inpatient setting. PROCEDURE We undertook a prospective cohort QI study to decrease time to antibiotics for neutropenic pediatric oncology inpatients with new fever to <60 min. Our key intervention was discussion of a plan in case of new fever, including antibiotic(s) to be started, for each patient on rounds. Timing for each step in the process, from fever identification to antibiotic administration, was measured through the electronic medical record for each fever event. RESULTS The median time to antibiotics during the 3-three month intervention study period was 76.0 min, although the distribution was skewed due to several long outliers (mean 142.5, interquartile range 51-206, range 47-593 min). Time to antibiotics was significantly shorter when a fever contingency plan was documented in the most recent note than not (mean 102 vs. 254 min, P = 0.039). Over the total 2.75 year data-collection period, the quarterly percentage of patients receiving antibiotics within 60 min has improved from 35 to 65, whereas quarterly mean time to antibiotics has improved from 99 to 50 min. CONCLUSIONS Daily discussion of a fever contingency plan appears effective in decreasing the time to antibiotics for neutropenic pediatric oncology inpatients with new fever, likely by circumventing the need for multi-level discussion of the antibiotic plan when fever is identified.
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Affiliation(s)
- Adam L. Green
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Joanna Yi
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Natalie Bezler
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Yana Pikman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Venée N. Tubman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Esther A. Obeng
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Teresa O’Neil
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Robert Mersereau
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Lisa Morrissey
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Amy L. Billett
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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Fever at Diagnosis of Pediatric Acute Lymphoblastic Leukemia: Are Antibiotics Really Necessary? J Pediatr Hematol Oncol 2015; 37:498-501. [PMID: 26376233 DOI: 10.1097/mph.0000000000000417] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION With new multidrug-resistant microbes and the paucity of new antibacterial agents, we must identify opportunities to safely minimize antibiotics. Current guidelines encourage empiric antibiotics in febrile patients with chemotherapy-induced neutropenia to reduce infection-related mortalities. No guidelines exist for children with isolated fever at presentation/diagnosis of acute lymphoblastic leukemia (ALL) and before starting chemotherapy. This study evaluates the incidence of bacteremia in this subpopulation. MATERIALS AND METHODS We retrospectively analyzed medical records of 230 consecutive patients under 21 years of age diagnosed with ALL at Children's Hospital & Research Center Oakland (CHRCO) from January 2003 through October 2013. We focused on blood cultures obtained within 24 hours of presentation to CHRCO, which was before general anesthesia for a procedure or systemic chemotherapy. RESULTS Among 221 patients who met the inclusion criteria, 126 (57%) were febrile and had blood cultures obtained. Two patients (1.6%) had positive blood cultures consistent with bacteremia; 1 had group A β-hemolytic streptococcus and the other had Escherichia coli. DISCUSSION Given the rarity of bacteremia in this subpopulation at our institution, we recommend more judicious use of antibiotics in children with isolated fever at time of ALL diagnosis. We encourage other institutions to conduct similar investigations.
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Abstract
BACKGROUND To evaluate the clinical feature and outcome of invasive fungal infections (IFI) in children with hematologic and malign diseases. PATIENTS AND METHODS The medical records of children with hematologic and malignant diseases, who were hospitalized at our hospital between January 2010 and December 2011, were reviewed. Proven, probable, and possible IFIs were diagnosed according to the revised definitions of the European Organization for Research and Treatment of Cancer/Mycosis Study Group. The demographic, clinical, and laboratory characteristics of the patients who met the study criteria were evaluated. RESULTS IFI was diagnosed in 67 (7.2%) febrile episodes of 56 patients, of which 10 (1.2%) were proven, 20 (2%) probable, and 37 (4%) possible IFI. Blood culture of 10 cases with proven IFI yielded yeast and the most common isolated agent was Candida parapsilosis. Seventy percent of cases with fungemia had central venous catheter (CVC). Twenty cases with probable IFI had invasive mold infection. The cases with mold infection had higher median C-reactive protein values, lower neutrophil counts, and longer duration of neutropenia compared with the cases with yeast infection. A total of 14 patients (20.9%) died. Presence of CVC, bone marrow transplantation, total parenteral nutrition, prolonged fever, and proven/probable IFI were detected more often in patients who died, compared with patients who survived. CONCLUSIONS IFIs are important causes of death in children with hematologic and malignant diseases. Mold infections are seen more frequently in cases with prolonged and profound neutropenia, and invasive yeast infections, especially with non-albicans Candida species, in cases with CVC. Early and effective treatment considering these findings will help to decrease the mortality.
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Abstract
OBJECTIVE To describe the characteristics and clinical course of febrile neutropenia (FN) in pediatric patients admitted to a comprehensive cancer center in Jordan. METHODS This is a 6-month prospective observational study. Patients admitted with FN were identified. Patient demographics, duration since last chemotherapy, use of granulocyte colony-stimulating factor, presence of central lines, transfer to the intensive care unit, length of hospital stay, mortality, and the results of all cultures were recorded. RESULTS One hundred and nine episodes for 88 patients were included, with a median age of 6 years (range, 1 to 19 y) and 55% were females. Median duration since last chemotherapy was 7 days (range, 1 to 33 d); median duration of hospital stay was 7 days (range, 1 to 81 d). Transfer to the intensive care unit was required for 11% of episodes, and there were no deaths. Positive cultures were reported in 18.4% episodes. Pathogens isolated were gram-positive organisms (50%), gram-negative organisms (20%), viral (25%), and fungal (5%). Positive blood cultures were significantly more in episodes with central lines compared with those with no central lines (P=0.04). CONCLUSIONS FN episodes had favorable outcomes and were mostly associated with negative cultures. There were differences between the microbiologic profiles reported in this study, compared with what has been previously described.
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