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Henry M, Sung L. Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia. Pediatr Clin North Am 2015; 62:27-46. [PMID: 25435110 DOI: 10.1016/j.pcl.2014.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Meret Henry
- Division of Hematology/Oncology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien, Detroit, MI 48201, USA.
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
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Bone suppression increases the visibility of invasive pulmonary aspergillosis in chest radiographs. PLoS One 2014; 9:e108551. [PMID: 25279774 PMCID: PMC4184785 DOI: 10.1371/journal.pone.0108551] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022] Open
Abstract
Objective Chest radiographs (CXR) are an important diagnostic tool for the detection of invasive pulmonary aspergillosis (IPA) in critically ill patients, but their diagnostic value is limited by a poor sensitivity. By using advanced image processing, the aim of this study was to increase the value of chest radiographs in the diagnostic work up of neutropenic patients who are suspected of IPA. Methods The frontal CXRs of 105 suspected cases of IPA were collected from four institutions. Radiographs could contain single or multiple sites of infection. CT was used as reference standard. Five radiologists and two residents participated in an observer study for the detection of IPA on CXRs with and without bone suppressed images (ClearRead BSI 3.2; Riverain Technologies). The evaluation was performed separately for the right and left lung, resulting in 78 diseased cases (or lungs) and 132 normal cases (or lungs). For each image, observers scored the likelihood of focal infectious lesions being present on a continuous scale (0–100). The area under the receiver operating characteristics curve (AUC) served as the performance measure. Sensitivity and specificity were calculated by considering only the lungs with a suspiciousness score of greater than 50 to be positive. Results The average AUC for only CXRs was 0.815. Performance significantly increased, to 0.853, when evaluation was aided with BSI (p = 0.01). Sensitivity increased from 49% to 66% with BSI, while specificity decreased from 95% to 90%. Conclusion The detection of IPA in CXRs can be improved when their evaluation is aided by bone suppressed images. BSI improved the sensitivity of the CXR examination, outweighing a small loss in specificity.
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Abstract
OBJECTIVES The objectives of this study are to identify the characteristics of febrile gynecologic oncology patients and to evaluate the utility of common diagnostic procedures used to assess the etiologies of their fevers. METHODS/MATERIALS Retrospective data were collected for 200 consecutive patients admitted to the gynecologic oncology service at 1 institution between January 2008 and December 2012 for a diagnosis of fever. Data were collected using contingency tables, and the χ test was used as appropriate. RESULTS Of the patients admitted for evaluation of fever, 142 (71%) of 200 had a documented fever during hospitalization. The most common etiologies of fever in this population were urinary tract infections (28%) and bloodstream infections (27%), whereas 24% of those admitted for fever did not have a source identified. Abdominal/pelvic computed tomography (CT) scans established the etiology of fever in 53 (60%) of the 89 patients tested, whereas chest x-ray and chest CT were diagnostic for 6% and 21%, respectively. Blood and urine cultures were diagnostic in 29% and 32% of cases, respectively. Patients admitted within 30 days of surgery had a higher percentage of wound infections (38% vs 10%, P < 0.001) as compared with those admitted for more than 30 days after surgery. CONCLUSIONS The initial evaluation of the febrile gynecologic oncology patient without obvious source by history and examination should include urinalysis with reflex culture and blood cultures. Abdominopelvic and chest CT may be useful when fever persists and initial assessment is unrevealing. Chest x-ray is commonly done but infrequently diagnostic. Wound exploration may be important in patients with fevers for more than 30 days after surgery.
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Fieber und Neutropenie nach Chemotherapie. Monatsschr Kinderheilkd 2013. [DOI: 10.1007/s00112-012-2781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Britton BM, Kelleher ME, Gregor TP, Sorenmo KU. Evaluation of factors associated with prolonged hospital stay and outcome of febrile neutropenic patients receiving chemotherapy: 70 cases (1997-2010). Vet Comp Oncol 2012; 12:266-76. [DOI: 10.1111/vco.12001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- B. M. Britton
- Department of Clinical Studies, School of Veterinary Medicine; University of Pennsylvania; Philadelphia PA USA
| | - M. E. Kelleher
- Department of Clinical Studies, School of Veterinary Medicine; University of Pennsylvania; Philadelphia PA USA
| | - T. P. Gregor
- Department of Clinical Studies, School of Veterinary Medicine; University of Pennsylvania; Philadelphia PA USA
| | - K. U. Sorenmo
- Department of Clinical Studies, School of Veterinary Medicine; University of Pennsylvania; Philadelphia PA USA
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Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 2012; 30:4427-38. [PMID: 22987086 DOI: 10.1200/jco.2012.42.7161] [Citation(s) in RCA: 239] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN). METHODS The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations. RESULTS Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented. CONCLUSION This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.
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Phillips B, Wade R, Westwood M, Riley R, Sutton AJ. Systematic review and meta-analysis of the value of clinical features to exclude radiographic pneumonia in febrile neutropenic episodes in children and young people. J Paediatr Child Health 2012; 48:641-8. [PMID: 22050289 DOI: 10.1111/j.1440-1754.2011.02211.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Children and young people who present with febrile neutropenia (FNP) secondary to malignancies or their treatment frequently do not undergo routine chest radiography. With shorter courses of antibiotic therapy, failure to recognise pneumonia and consequent under-treatment could produce significant problems. METHODS The review was conducted determine the value of the absence of clinical features of lower respiratory tract infection in excluding radiographic pneumonia at presentation of FNP using Centre for Reviews and Dissemination methods. It was registered with the HTA Registry of systematic reviews, CRD32009100453. Ten bibliographic databases, conference proceedings, reference lists and citations were searched. Cohort studies which compared clinical examination to radiographic findings were included. Results were summarised by random-effects meta-analysis. RESULTS Four studies were included. Synthesis of the three higher-quality studies gave imprecise estimates of the average sensitivity (75%; 95% CI 52% to 89%) and average specificity (69%; 95% CI 57% to 78%) for clinical examination in the detection of radiographic pneumonia. If the prevalence of pneumonia is 5%, these estimates produce a negative predictive value of 98% (95% CI 96% to 99%). Alternatively, there remains a 1.9% probability of pneumonia (95% CI 0.7% to 4.2%). CONCLUSION Signs and symptoms of lower respiratory infection have only moderate sensitivity and specificity for pneumonia; the low prevalence of the condition justifies the routine withholding of chest radiographs. However, for those with a predisposition to pneumonia, or re-presenting after a short course of antibiotic therapy, a chest X-ray should be performed despite an absence of signs.
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Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.
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Roberts SD, Wells GM, Gandhi NM, York NR, Maron G, Razzouk B, Hayden RT, Kaste SC, Shenep JL. Diagnostic value of routine chest radiography in febrile, neutropenic children for early detection of pneumonia and mould infections. Support Care Cancer 2012; 20:2589-94. [PMID: 22278307 DOI: 10.1007/s00520-011-1366-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 12/26/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite recent studies failing to demonstrate the value of routine chest radiography (CXR) in the initial evaluation of the febrile neutropenic patient with cancer, this screening test is advocated by some experts. We evaluated the benefits of CXR for early diagnosis of pulmonary infection at St. Jude Children's Research Hospital (SJCRH) with emphasis on early recognition of mould infections. PATIENTS AND METHODS We reviewed the courses of 200 consecutive febrile neutropenic pediatric patients to determine if routine CXR at initial evaluation was useful in the identification of clinically occult pneumonia. We also reviewed all cases of proven or probable mould infections from the opening of SJCRH in 1962 until 1998 when routine CXR was no longer practiced in our institution to identify cases that were first recognized by routine CXR. RESULTS Of 200 febrile neutropenic patients, pulmonary abnormalities consistent with pneumonia were detected by routine CXR in only five patients without pulmonary signs or symptoms. In only one case was a change in management considered. Of the 70 patients with pulmonary mould infection identified from 1962 to 1998, routine CXR was performed in 45 patients at the onset of a febrile, neutropenic episode in which a mould infection was diagnosed. Routine CXR was pivotal in the recognition of the mould infection in only two cases over this 36-year period. CONCLUSION CXR is warranted in the evaluation of the newly febrile neutropenic pediatric oncology patient only when respiratory signs or symptoms are present.
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Affiliation(s)
- Stefan D Roberts
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN 38105-3678, USA
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Cox JA, DeMasi J, McCollom S, Jackson G, Scothorn D, Aquino VM. The diagnostic utility of routine chest radiography in the evaluation of the initial fever in patients undergoing hematopoietic stem cell. Pediatr Blood Cancer 2011; 57:666-8. [PMID: 21826781 DOI: 10.1002/pbc.22911] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 10/14/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND A routine chest radiograph is often performed to evaluate initial fever in patients undergoing hematopoietic stem cell transplantation (HSCT) given the signs and symptoms of infectious pulmonary pathology may be subtle or absent. Studies in patients receiving conventional chemotherapy have shown that chest radiographs do not appear to be helpful in the evaluation of asymptomatic patients with febrile neutropenia. We performed a retrospective review of pediatric stem cell transplant recipients to determine if chest radiographs are useful in the evaluation of initial fever. PROCEDURE We retrospectively identified 81 consecutive pediatric hematopoietic stem transplant recipients who had a chest radiograph performed as a routine part of the evaluation of initial fever during stem cell transplantation. RESULTS Seventy-six (94%) of the chest radiographs performed had no evidence of pulmonary infiltrate. Of the five children with positive radiographs, three had symptomatic respiratory infection and two (40%) were asymptomatic. One asymptomatic patient had a history of pulmonary infection with persistent stable infiltrates prior to transplantation. This patient did not have any evidence of pneumonia during the transplant. The second asymptomatic patient had subsequent resolution of the infiltrate with antibiotic administration. None of the patients had a change made in the empiric antibiotic regimen based upon the results of the chest film. CONCLUSIONS Routine radiographs are not useful in the evaluation of asymptomatic children at the time of an initial febrile event while undergoing HSCT.
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Affiliation(s)
- Jennifer A Cox
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9063, USA
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Meckler G, Lindemulder S. Fever and Neutropenia in Pediatric Patients with Cancer. Emerg Med Clin North Am 2009; 27:525-44. [DOI: 10.1016/j.emc.2009.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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te Poele EM, Tissing WJE, Kamps WA, de Bont ESJM. Risk assessment in fever and neutropenia in children with cancer: What did we learn? Crit Rev Oncol Hematol 2009; 72:45-55. [PMID: 19195908 DOI: 10.1016/j.critrevonc.2008.12.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 12/04/2008] [Accepted: 12/18/2008] [Indexed: 11/15/2022] Open
Abstract
Children with cancer treated with chemotherapy are susceptible to bacterial infections and serious infectious complications. However, fever and neutropenia can also result from other causes, for which no antibiotic treatment is needed. In the past decades attempts have been made to stratify the heterogeneous group of pediatric cancer patients with fever and neutropenia into high- and low-risk groups for bacterial infections or infectious complications. Strategies for risk assessment have resulted in treatment regimens with early discharge or even no hospital admission at all, and/or treatment with oral or no antibiotics. We will provide a historical overview of the changing approach to low-risk fever and neutropenia, and we will also try to identify clear and objective parameters for risk assessment strategies and illustrate their relationship to innate immunity. In the future, new insights into genetic susceptibility on neutropenic fever might be of use in children with cancer with fever and neutropenia.
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Affiliation(s)
- Esther M te Poele
- Department of Pediatrics, Division of Pediatric Oncology/Hematology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
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Korones DN. Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer? Pediatr Blood Cancer 2004; 43:715-7. [PMID: 15481080 DOI: 10.1002/pbc.20226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- David N Korones
- University of Rochester Medcial Center, Rochester, NY 14642, USA.
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Renoult E, Buteau C, Turgeon N, Moghrabi A, Duval M, Tapiero B. Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer? Pediatr Blood Cancer 2004; 43:224-8. [PMID: 15266405 DOI: 10.1002/pbc.20127] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The yield of routine chest radiography (CXR) as part of the initial management of febrile neutropenic pediatric oncology patients is questionable. PROCEDURE We retrospectively analyzed the clinical records of neutropenic (absolute neutrophil count < or = 0.5 x 10(9)/L) children with cancer, admitted with oral temperature > or = 38 degrees C to our institution, between January 2001 and October 2002. Following admission, patients received tobramycin plus (piperacillin or ticarcillin-clavulanic acid). Admission routine CXRs were reviewed. Clinical and radiological features were compared with the discharge diagnosis. Age, underlying disease, and the presence of pulmonary symptoms or signs were studied as possible predictors of CXR findings related to pneumonia. RESULTS In total, 88 patients experienced 170 episodes of fever. A routine admission CXR was obtained for 157 of the episodes. Radiologists found 20 (12.7%) abnormal CXR (6 with a segmental or lobar consolidation considered as a pneumonia). In addition, two patients with abnormal admission CXR developed lobar consolidation on a repeat film, later in their hospital course. There were no differences in age and type of underlying disease between children with or without pneumonia. Respiratory symptoms were initially present in 58 cases. Seven (12%) had pneumonia. Among the 99 asymptomatic cases only one (1%) patient had a pneumonia (P = 0.0041). This child had a positive blood culture for P. aeruginosa at the time of admission. None of the children had initial therapy modified on the basis of radiologic findings. CONCLUSION In this study, pneumonia is an unusual cause of fever (5%), especially in the absence of respiratory signs or symptoms (1%). Admission CXR should be reserved for the neutropenic pediatric oncology patient presenting with fever and abnormal respiratory findings.
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Affiliation(s)
- Edith Renoult
- Infectious Diseases Division, Hôpital Sainte-Justine, University of Montreal (Quebec), Canada.
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Oude Nijhuis CSM, Gietema JA, Vellenga E, Daenen SMGJ, De Bont ESJM, Kamps WA, Groen HJM, van der Jagt EJ, van der Graaf WTA. Routine radiography does not have a role in the diagnostic evaluation of ambulatory adult febrile neutropenic cancer patients. Eur J Cancer 2004; 39:2495-8. [PMID: 14602135 DOI: 10.1016/j.ejca.2003.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cancer patients treated with chemotherapy are susceptible to bacterial infections. When an adult patient presents with febrile neutropenia, standard diagnostic care includes physical examination, laboratory diagnostics, chest X-ray (CXR) and sinus radiography. However, the yield of routine radiography in the diagnostic evaluation of ambulatory adult febrile neutropenic patients with normal findings at their physical examination is questionable. Two CXRs and one sinus X-ray were obtained in 109 and 106 febrile neutropenic episodes after chemotherapy in ambulatory adult patients who had no clinical signs suggesting pulmonary infection or sinusitis. We found that in only two of 109 (1.8%; 95% Confidence Interval (CI): 0.3-5.8%) febrile neutropenic episodes without clinical signs of new pulmonary disease, the CXR showed a consolidation suggesting pneumonia. In addition, in five of 88 (5.7%; 95% CI: 2.2-12.0%) febrile episodes in asymptomatic patients, sinus X-ray suggested sinusitis. In none of these seven episodes was a change of antibiotic therapy necessary. In the absence of clinical signs indicating pneumonia or sinusitis, the yield of CXR and sinus radiography in ambulatory adult cancer patients presenting with febrile neutropenia is minimal; CXR and sinus radiography should no longer be performed on a routine basis.
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Affiliation(s)
- C S M Oude Nijhuis
- Division of Paediatric Oncology/Haematology, Beatrix Children's Hospital, University Hospital Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Navigante AH, Cerchietti LCA, Costantini P, Salgado H, Castro MA, Lutteral MA, Cabalar ME. Conventional chest radiography in the initial assessment of adult cancer patients with fever and neutropenia. Cancer Control 2002; 9:346-51. [PMID: 12228760 DOI: 10.1177/107327480200900411] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alfredo H Navigante
- Supportive Care Division, Instituto de Oncologia Angel H. Roffo, Universidad de Buenos Aires, Argentina
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Roy V, Ali LI, Selby GB. Routine chest radiography for the evaluation of febrile neutropenic patients after autologous stem cell transplantation. Am J Hematol 2000; 64:170-4. [PMID: 10861811 DOI: 10.1002/1096-8652(200007)64:3<170::aid-ajh5>3.0.co;2-p] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chest radiographs are routinely obtained for diagnostic evaluation of neutropenic febrile patients. We investigated the frequency of chest radiographic abnormalities during febrile episodes after autologous PBSC transplants and assessed the relationship of these abnormalities to past history of pulmonary disease, pre-transplant chest radiographic abnormalities, and pulmonary signs or symptoms at time of fever. We also studied the impact of chest radiographic findings on patient management. Sixty-one consecutive adult autologous PBSC transplant recipients were studied. Fifty-two (85%) developed fever, and 20 (38%) of these showed new chest radiographic abnormalities suggestive of pulmonary infection. Patients with pre-transplant chest radiographic abnormalities were more likely to develop additional abnormalities with fever post-transplant. Pulmonary symptoms or signs had low sensitivity or specificity for predicting radiographic abnormalities. Only 40% of patients with pulmonary symptoms or signs had an abnormal chest radiograph. Twenty-six percent of patients with abnormal chest radiographs had no clinical findings suggestive of pulmonary infection. The identification of chest radiographic abnormality did not change empiric antibiotic treatment in any patient. The role of routine chest radiography for diagnostic evaluation of febrile autologous PBSC transplant patients should be re-evaluated.
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Affiliation(s)
- V Roy
- Department of Medicine, Hematology-Oncology Section, University of Oklahoma Health Science Center, Oklahoma City 73190, USA.
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Morris C, Vichinsky E, Styles L. Clinician assessment for acute chest syndrome in febrile patients with sickle cell disease: is it accurate enough? Ann Emerg Med 1999; 34:64-9. [PMID: 10381996 DOI: 10.1016/s0196-0644(99)70273-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To determine whether the use of empiric chest radiography (CXR) is of significant value in detecting clinically unsuspected acute chest syndrome (ACS) in febrile patients with sickle cell disease (SCD). METHODS Patients with SCD presenting to the emergency department and hematology clinic with temperature greater than or equal to 38 degrees C were prospectively evaluated using a physician-completed questionnaire. The questionnaire included inquiries into the patient's physical signs and symptoms and the physician's clinical impression for the presence of ACS. The questionnaire was completed before obtaining CXR results in all patients. RESULTS Seventy-three patients with SCD with 96 febrile events were evaluated over a 1-year period. Twenty-four percent (23/96) of the patients had CXR evidence of ACS. On the basis of the questionnaire data, 61% (14/23) of ACS cases were not clinically suspected by the evaluating physician before obtaining CXR. Comparing the patients with and without ACS revealed that, with the exception of splinting (4/23 [17%] versus 0/73 [0%]), no symptom or physical examination finding helped to identify which patients had ACS. Fifty-seven percent of patients with ACS had completely normal findings on physical examination. The presentation of patients with clinically detected versus clinically unsuspected ACS also did not differ significantly. Length of hospitalization, oxygen use, and need for transfusion were the same in both the unsuspected and detected ACS groups. Overall physician sensitivity for predicting ACS was only 39%, and diagnostic accuracy did not improve significantly with increasing levels of pediatric training. CONCLUSION ACS is common in patients with SCD who present with fever and was grossly underestimated by evaluating physicians. History and physical examination appear to be of little value in defining which febrile patients require CXR. In view of the mortality and morbidity associated with ACS, empiric CXR should be considered when evaluating a febrile patient with SCD.
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Affiliation(s)
- C Morris
- Departments of Emergency Medicine and Hematology/Oncology, Children's Hospital Oakland, Oakland, CA, USA.
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Dompeling EC, Donnelly JP, Raemaekers JM, Deresinski SC, Feld R, De Pauw BE. Evolution of the clinical manifestations of infection during the course of febrile neutropenia in patients with malignancy. Infection 1998; 26:349-54. [PMID: 9861558 DOI: 10.1007/bf02770834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The impact of a standardized set of diagnostic interventions on the further management of 968 episodes of fever in neutropenic cancer patients who did not respond to initial therapy was assessed prospectively. At the onset of fever, 65% of patients had no additional signs of infection, whereas skin and soft tissue infections were present in 12%, and clinical sepsis and gastrointestinal infections in 8% each. After 72 h, 41% of the fevers still remained unexplained. New foci of infection emerged in 11% of the cases involving mainly the lungs, skin and soft tissues, and urinary tract. The presence of a lower respiratory tract infection or a microbiologically defined infection of any sort was associated with higher mortality than other types of infection were. Changes in initial antibiotic therapy were based on the results of the diagnostic measures specified in the protocol in only 15% of the cases.
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Affiliation(s)
- E C Dompeling
- Div. of Hematology, University Hospital St. Radboud, Nijmegen, The Netherlands
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Abstract
A broad classification of immune defects provides a framework for the approach to fever in the immunocompromised host. Practical, historical, and physical examination findings are reviewed, and common clinical scenarios are highlighted. A general initial work-up and treatment plan are outlined.
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Affiliation(s)
- M Mendelson
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, USA.
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Abstract
Episodes of infection occurring in neutropenic patients are often associated with high levels of morbidity and mortality and prompt, accurate diagnosis allowing the rapid instigation of appropriate treatment can lead to an improved outcome. Recent developments in laboratory technology have increased the range of investigations available to the physician. The improved sensitivity of traditional microbiological culture, methods for antigen and antibody detection and the advances in molecular biology are among the reasons for an increased ability to detect both familiar and novel pathogens. This article describes the current methods available for determining the aetiology of an infectious episode in these patients. A plan of management for investigation of febrile episodes in neutropenic patients is suggested.
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Affiliation(s)
- T Gillespie
- Department of Microbiology, Western General Hospital, Edinburgh, UK
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Sahu S, Bapna A, Pai SK, Nair CN, Kurkure PA, Advani SH. Outpatient antimicrobial protocol for febrile neutropenia: a nonrandomized prospective trial using ceftriaxone, amikacin, and oral adjuvant agents. Pediatr Hematol Oncol 1997; 14:205-11. [PMID: 9185205 DOI: 10.3109/08880019709009490] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Broad-spectrum antimicrobial therapy has revolutionized the management of febrile neutropenia (FN) in cancer patients. In vogue is an effective therapy an an outpatient basis. One thousand three hundred episodes of FN observed in 70 pediatric solid tumors (STs) and 65 cases of hematomalignancy (HM) at a median age of 5.5 years were treated with a protocol using once-a-day injectable ceftriaxone plus amikacin and other oral adjuvant antimicrobial agents. The mean duration of FN in the ST group was 4.0 +/- 1.2 days and in the HM group was 5.0 +/- 2.5 days. The mean duration of antimicrobial cover in the ST group was 5.0 +/- 1.75 days and in the HM group was 6.0 +/- 1.5 days. The overall recrudescence rate was 6% and the mean duration to recrudescence was 4 +/- 1.5 days (range 3-6 days). The objectives of this protocol were cost reduction and utilization of the available inpatient resources optimally by reducing the pressures of hospitalization for febrile neutropenia. We concluded that a selected group of patients with FN can be effectively managed with this regimen on an outpatient basis.
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Affiliation(s)
- S Sahu
- Department of Medical Oncology (Paediatric Division), Tata Memorial Hospital, Bombay, India.
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24
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Abstract
Fever in the neutropenic patient following myelosuppressive chemotherapy is a medical emergency. Appropriate antimicrobial therapy can dramatically reduce infection-related morbidity and mortality. This article reviews the rationale and methodology of treatment as well as its applicability to other neutropenic states. The utility of adjunct therapy with granulocyte- stimulating compounds is also discussed.
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Affiliation(s)
- S J Chanock
- Infectious Disease Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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25
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Abstract
Improvement in supportive care including the introduction of new antibiotics, antiviral and antifungal agents and haematopoietic growth factors have all contributed to a decreased chemotherapy-related mortality and morbidity in cancer patients. However, infection during neutropenia is still a major complication and a great concern for the clinician responsible for the patient. Management of infectious complications in the neutropenic patient is reviewed.
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Affiliation(s)
- P Engervall
- Department of Medicine, Karolinska Hospital, Stockholm, Sweden
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Lee JW, Pizzo PA. Management of the Cancer Patient with Fever and Prolonged Neutropenia. Hematol Oncol Clin North Am 1993. [DOI: 10.1016/s0889-8588(18)30213-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Affiliation(s)
- P A Pizzo
- Pediatric Branch, National Cancer Institute, Bethesda, MD 20892
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28
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Wilkinson TJ, Robinson BA. Neutropenic sepsis complicating treatment of solid tumours, lymphoma and myeloma. Clin Oncol (R Coll Radiol) 1992; 4:355-61. [PMID: 1463688 DOI: 10.1016/s0936-6555(05)81125-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ninety-three episodes of fever or infection while neutropenic (defined as neutrophil count < 2.0 x 10(9)/l) occurred in 76 patients treated for solid tumours, lymphoma and myeloma over a 4-year period. Most followed the first (39%) or second (18%) cycle of chemotherapy. The neutrophil count at onset of sepsis was < 0.5 x 10(9)/l in 69%. Pathogens were isolated in 32 episodes (34%) and a clinical focus detected in a further 19 (20%). Gram negative bacteria accounted for 51% of pathogens; 49% of bacteria were isolated from blood, 65% of them were Gram negative. The initial antibiotic regimen was cefuroxime with gentamicin or tobramycin in 76 episodes. Fever or infection resolved on first line antibiotics in 78%. The mean duration of antibiotic therapy was 7.6 days. Antibiotic therapy was changed following urine culture in 1.5% of 66 episodes and following chest radiography in 5.8% of 69 episodes, where these tests were performed. Nine (9.6%) patients died from infection, all of whom were receiving second line salvage chemotherapy. Three other patients died of progressive malignancy with sepsis present. In six major diagnostic groups, 56 episodes of infection or fever complicated 4% of chemotherapy cycles.
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Affiliation(s)
- T J Wilkinson
- Oncology Service, Canterbury Area Health Board, Christchurch, New Zealand
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29
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Pizzo PA, Rubin M, Freifeld A, Walsh TJ. The child with cancer and infection. I. Empiric therapy for fever and neutropenia, and preventive strategies. J Pediatr 1991; 119:679-94. [PMID: 1941374 DOI: 10.1016/s0022-3476(05)80281-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- P A Pizzo
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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30
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Katz JA, Bash R, Rollins N, Cash J, Buchanan GR. The yield of routine chest radiography in children with cancer hospitalized for fever and neutropenia. Cancer 1991; 68:940-3. [PMID: 1913490 DOI: 10.1002/1097-0142(19910901)68:5<940::aid-cncr2820680505>3.0.co;2-v] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A routine admission chest radiograph (CXR) in pediatric patients with cancer who are admitted to the hospital for fever and neutropenia has been advised because the signs and symptoms of pneumonia may be absent. The authors studied 131 consecutive patient admissions for fever and neutropenia to evaluate the diagnostic yield of routine CXR. All patients had a complete history, physical examination, complete blood count, blood culture, urinalysis, urine culture, and CXR. Patients routinely started ceftazidime monotherapy. Results of the CXR were correlated with the presence or absence of signs and symptoms of respiratory disease. Of 128 CXR results, 26 (20%) were abnormal (13 with known malignant disease, 2 with atelectasis, 3 with peribronchial cuffing, and 8 with pneumonia [6%]). Three patients with pneumonia were asymptomatic. Therefore, only 3 of 128 patients (2.3%) had pneumonia on CXR not suspected by physical examination. None would have had initial therapy modified based on the CXR finding alone. The authors concluded that the incidence of pneumonia in a child with fever and neutropenia is low and that routine CXR at diagnostic evaluation is unnecessary in the asymptomatic ambulatory patient.
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Affiliation(s)
- J A Katz
- Children's Medical Center of Dallas, Texas
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31
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Jochelson MS. The Treated Thorax. Radiol Clin North Am 1990. [DOI: 10.1016/s0033-8389(22)01259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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