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Clément L, Hélène D, Maud M, Chrystelle D, Constance B, Fréderic M, France R, Pilar GHM, José-Miguel TD, Blandine R. Safety of empirical antibiotic therapy discontinuing for fever of unknown origin during high-risk neutropenia in children. J Infect 2024; 88:106171. [PMID: 38697268 DOI: 10.1016/j.jinf.2024.106171] [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: 02/21/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND ECIL-2021 recommends discontinuing empirical antibiotic therapy (EAT) in febrile-neutropenic children after 72 h of treatment and at least 24-48 h of apyrexia in the case of fever of unknown origin (FUO). These guidelines are rarely applied to high-risk children's neutropenia. MATERIAL AND METHODS We retrospectively included all consecutive FUO episodes occurring during profound neutropenia ≥ 10 days in children in our institution. We evaluated the safety of EAT discontinuation in patients for whom the ECIL guidelines were followed compared to those for whom they didn't. We used a combined criterion of mortality and intensive care unit admission at 30 days. We identified risk factors for recurrent fever after EAT discontinuation. RESULTS Fifty-one FUO episodes occurred in 37 patients. EAT discontinuation followed ECIL guidelines in 19 (37 %) episodes. No deaths and-or transfers in ICU occurred in the ECIL group. The duration of EAT was shorter by nine days in the group following ECIL guidelines (p < 0.001). We observed 14 (27 %) episodes of recurrent fever. Mucositis was significantly associated with recurrent fever (p < 0.01). CONCLUSION EAT discontinuation seems feasible and safe in FUO during prolonged febrile neutropenia in children. However, mucosal lesions should prompt thorough surveillance due to the risk of recurrent fever.
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Affiliation(s)
- Lemaigre Clément
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France
| | - Deutch Hélène
- Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Meligne Maud
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Dupraz Chrystelle
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | | | - Millot Fréderic
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Roblot France
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France
| | - Gallego-Hernanz Maria Pilar
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Torregrosa-Diaz José-Miguel
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Rammaert Blandine
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France.
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Barnbrock A, Salmanton-García J, Lankes F, Bochennek K, Schöning S, Lehrnbecher T. No Impact of Dietary Restrictions on the Risk for Infection in Pediatric Patients With Cancer: A Monocenter Analysis. JCO Oncol Pract 2024; 20:503-508. [PMID: 38261984 DOI: 10.1200/op.23.00553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/31/2023] [Indexed: 01/25/2024] Open
Abstract
PURPOSE Prophylactic anti-infective strategies are used in patients with cancer to decrease the risk for infection. Dietary restrictions do not allow raw vegetables and fresh fruits to limit the introduction of potentially harmful pathogens in the gastrointestinal tract, but the efficacy is unclear. PATIENTS AND METHODS In this study analyzing the impact of the dietary restrictions on infectious complications, all children treated between April 2014 and March 2018 for ALL and AML or non-Hodgkin lymphoma (NHL) were included. Dietary restrictions were standard until March 2016, but were stopped in April 2016. Patients with dietary restrictions (treated April 2014-March 2016) and patients not advised for dietary restrictions (treated April 2016-March 2018) were compared regarding infectious complications, including bloodstream infection, pneumonia, diarrhea, and fever of unknown origin (FUO). RESULTS Eighty-six patients (25 female; 62 ALL; nine AML, 15 NHL) experienced 223 infections. The 46 patients with dietary restrictions and the 40 patients without food restrictions did not significantly differ regarding the number of infections per patient, bloodstream infections, pneumonia, diarrhea, FUO, admission to intensive care, and death. CONCLUSION Our data suggest that dietary restrictions do not affect the risk for infectious complications. Therefore, the indication of dietary restrictions should be reconsidered in pediatric patients with cancer.
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Affiliation(s)
- Anke Barnbrock
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Jon Salmanton-García
- Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Excellence Center for Medical Mycology, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Franziska Lankes
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Konrad Bochennek
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Stefan Schöning
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
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Dupuis LL, Fisher BT, Sugalski AJ, Grimes A, Nuño M, Ramakrishnan S, Beauchemin MP, Robinson PD, Santesso N, Walsh A, Wrightson AR, Yu L, Parsons SK, Sung L. Clinical practice guideline-inconsistent management of fever and neutropenia in pediatric oncology: A Children's Oncology Group study. Pediatr Blood Cancer 2024; 71:e30880. [PMID: 38291716 PMCID: PMC10937100 DOI: 10.1002/pbc.30880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/29/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND The primary objective was to measure the proportion of episodes where care delivery was inconsistent with selected recommendations of a clinical practice guideline (CPG) on fever and neutropenia (FN) management. The influence of site size on CPG-inconsistent care delivery, and association between patient outcomes and CPG-inconsistent care were described. METHODS This retrospective, multicenter study included patients less than 21 years old with cancer who were at high risk of poor FN outcomes and were previously enrolled to a Children's Oncology Group (COG) study at participating National Cancer Institute Community Oncology Research Program (NCORP) institutions from January 2014 through December 2015. Patients were randomly selected for chart review by participating sites from a COG-generated list. Care delivered in each episode was adjudicated (CPG-consistent or CPG-inconsistent) against each of five selected recommendations. RESULTS A total of 107 patients from 22 sites, representing 157 FN episodes, were included. The most common CPG-inconsistent care delivered was omission of pulmonary computerized tomography in patients with persistent FN (60.3%). Of 74 episodes where assessment of four (episodes without persistent FN) or five (episodes with persistent FN) recommendations was possible, CPG-inconsistent care was delivered with respect to at least one recommendation in 63 (85%) episodes. Site size was not associated with CPG-inconsistent care delivery. No statistically significant association between CPG-inconsistent care and fever recurrence was observed. CONCLUSIONS In this cohort of pediatric patients at high risk of poor FN outcomes, CPG-inconsistent care was common. Opportunities to optimize resource stewardship by boosting supportive care CPG implementation are highlighted.
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Affiliation(s)
- LL Dupuis
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - BT Fisher
- The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, US
| | - AJ Sugalski
- University of Texas Health Science Center San Antonio, San Antonio, Texas, US
| | - A Grimes
- University of Texas Health Science Center San Antonio, San Antonio, Texas, US
| | - M Nuño
- Children’s Oncology Group, Monrovia, USA
| | | | - MP Beauchemin
- Columbia University Irving Medical Center, New York, USA
| | - PD Robinson
- Pediatric Oncology Group of Ontario, Toronto, Canada
| | - N Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - A Walsh
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, Phoenix, USA. University of Arizona, Phoenix, USA
| | - AR Wrightson
- Clinical Research Nurse Coordinator, Nemours Center for Cancer and Blood Disorders, Wilmington, USA
| | - L Yu
- LSUHSC/Children’s Hospital, New Orleans, USA
| | - SK Parsons
- Institute for Clinical Research and Health Policy Studies and Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - L Sung
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
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5
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Whitehurst DA, Friedman DL, Zhao Z, Sarma A, Snyder E, Dulek DE, Banerjee R, Kitko CL, Esbenshade AJ. A comprehensive assessment of the prolonged febrile neutropenia evaluation in pediatric oncology patients. Pediatr Blood Cancer 2024; 71:e30818. [PMID: 38110594 DOI: 10.1002/pbc.30818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/14/2023] [Accepted: 12/01/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Pediatric oncology patients with prolonged (≥96 hours) febrile neutropenia (absolute neutrophil count < 500/μL) often undergo an evaluation for invasive fungal disease (IFD) and other infections. Current literature suggests that beta-D-glucan (BDG), galactomannan, bronchoalveolar lavage (BAL), and computed tomography (CT) scans (sinus, chest, and abdomen/pelvis) may help determine a diagnosis in this population. METHODS In a retrospective cohort study of all cancer/stem cell transplant patients (diagnosed 2005-2019) from one pediatric hospital, all episodes with prolonged febrile neutropenia or IFD evaluations (defined as sending a fungal biomarker or performing a CT scan to assess for infection) were identified. RESULTS In total, 503 episodes met inclusion criteria and 64% underwent IFD evaluations. In total, 36.4% of episodes documented an infection after initiation of prolonged febrile evaluation, most commonly Clostridioides difficile colitis (6.4%) followed by a true bacterial bloodstream infection (BSI) (5.2%), proven/probable IFD (4.8%), and positive respiratory pathogen panel (3.6%). There was no difference in sinus CTs showing sinusitis (74% vs 63%, p = 0.46), whereas 32% of abdomen/pelvis CTs led to a non-IFD diagnosis, and 25% of chest CTs showed possible pneumonia. On chest CT, the positive predictive value (PPV) for IFD was 19% for nodules and 14% for tree and bud lesions. BDG had a PPV of 25% for IFD and GM 50%. BAL diagnosed IFD once and pneumocystis jirovecii pneumonia twice. CONCLUSIONS Chest CTs and abdomen/pelvis CTs provide clinically relevant information during the prolonged febrile neutropenia evaluation, whereas BDG, galactomannan, BAL, and sinus CTs have less certain utility.
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Affiliation(s)
| | - Debra L Friedman
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Asha Sarma
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Snyder
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E Dulek
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Ritu Banerjee
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Carrie L Kitko
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Adam J Esbenshade
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Schechter T, Tardif-Theriault C, Culos-Reed N, Lewis V, Orsey A, Diorio C, Tomlinson GA, Sung L. Yoga versus iPad active control for fatigue in paediatric cancer therapy: a randomised controlled trial. BMJ Support Palliat Care 2023:spcare-2023-004609. [PMID: 38160047 DOI: 10.1136/spcare-2023-004609] [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: 09/19/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES The primary objective was to determine if individualised yoga for hospitalised children receiving intensive chemotherapy was associated with less fatigue using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL MFS) compared with iPad control. METHODS This was a multicentre randomised controlled trial of individualised yoga in paediatric patients aged 8-18 years who were inpatients receiving intensive chemotherapy for leukaemia, lymphoma or haematopoietic cell transplantation. Participants were randomised to yoga or iPad groups; allocated programme was delivered individually by trained yoga instructors 5 days/week for 21 days. The primary outcome was day 21 guardian-reported general fatigue using the PedsQL MFS. Secondary outcomes included day 21 PedsQL sleep/rest and cognitive fatigue, Fatigue Scale and PedsQL Acute Cancer Module, and systemic opioid administration. RESULTS The study was closed early for poor accrual when 125/210 planned participants had been enrolled and randomised to yoga (n=62) or iPad (n=63). Guardian-reported PedsQL MFS general fatigue scores on day 21 were not significantly different between groups (adjusted difference 7.2, 95% CI -2.6 to 16.9) in favour of yoga. However, day 21 cognitive fatigue (adjusted difference 9.0, 95% CI 0.9 to 17.1), cognitive problems (adjusted difference 11.2, 95% CI 3.5 to 19.0) and communication (adjusted difference 10.6, 95% CI 0.8 to 20.4) were significantly better in the yoga compared with the iPad group. There were no significant differences in the other secondary outcomes including PedsQL sleep/rest fatigue (adjusted difference 4.9, 95% CI -3.5 to 13.3). CONCLUSIONS The effect of individualised yoga on general fatigue is uncertain in paediatric patients receiving intensive chemotherapy. However, yoga significantly improved cognitive fatigue and cognitive problems. TRIAL REGISTRATION NUMBER NCT02134782.
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Affiliation(s)
- Tal Schechter
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Victor Lewis
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Andrea Orsey
- Hematology Oncology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Caroline Diorio
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George A Tomlinson
- Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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Escobedo-Melendez G, Paniagua-Padilla J, Caniza MA. Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2023; 45:e798-e809. [PMID: 37526415 PMCID: PMC10521769 DOI: 10.1097/mph.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 06/20/2023] [Indexed: 08/02/2023]
Abstract
Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.
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Affiliation(s)
- Griselda Escobedo-Melendez
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jenny Paniagua-Padilla
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Miguela A. Caniza
- Departments of Global Pediatric Medicine and Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
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Parsons SK, Beauchemin MP, Dupuis L, Sugalski A, Wolfson JA, Santacroce SJ, Marchak JG, Sung L, Roth ME. Children's Oncology Group 2023 blueprint for research: Cancer care delivery research. Pediatr Blood Cancer 2023; 70 Suppl 6:e30579. [PMID: 37469004 PMCID: PMC10686255 DOI: 10.1002/pbc.30579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
The National Cancer Institute (NCI) has a 40-year history of initiatives to encourage the participation of community oncology sites into clinical trials research and clinical care. In 2014, the NCI re-organized to form the NCI Community Oncology Research Program (NCORP) network across seven research bases, including the Children's Oncology Group (COG), and numerous community sites. The COG portfolio for Cancer Care Delivery Research (CCDR), mirroring the larger NCORP network, has included two studies addressing guideline congruence, as an important marker of quality cancer care, and another focusing on financial toxicity, addressing the pervasive problems of healthcare cost. CCDR is a cross-cutting field that frequently examines intersectional aspects of healthcare delivery. With that in mind, we explicitly define domains of CCDR to propel our research agenda into the next phase of the NCORP CCDR program while acknowledging the complex and dynamic fields of clinical care, policy level decisions, research findings, and needs of communities served by the NCORP network that will inform the subsequent research questions. To ensure programmatic success, we will engage a broad interdisciplinary group of investigators and clinicians with expertise and dedication to community oncology and the populations they serve.
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Affiliation(s)
- Susan K. Parsons
- Institute for Clinical Research and Health Policy Studies and the Division of Hematology/Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Melissa P. Beauchemin
- Columbia University School of Nursing, CUIMC Minority/Underserved NCI Community Oncology Research Program, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Canada
| | - Aaron Sugalski
- University Health System Pediatric Blood and Cancer Center, Division Hematology/Oncology, University of Texas Health San Antonio, Joe R. and Teresa Lozano Long School of Medicine, San Antonio, Texas
| | - Julie Anna Wolfson
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham
| | - Sheila J. Santacroce
- School of Nursing and Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina
| | - Jordan G. Marchak
- Emory University School of Medicine, Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta, Georgia
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Michael E. Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Lirette MP, Wright N, Trottier ED, Beck CE. La prise en charge de la neutropénie fébrile chez les enfants et les adolescents immunocompétents. Paediatr Child Health 2023; 28:324-330. [PMID: 37484041 PMCID: PMC10362953 DOI: 10.1093/pch/pxac128] [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: 12/18/2021] [Accepted: 08/13/2022] [Indexed: 07/25/2023] Open
Abstract
La neutropénie fébrile est une manifestation clinique fréquente en pédiatrie, qui peut être associée à une infection bactérienne invasive. Cependant, le risque de ce type d'infection est faible chez les enfants et les adolescents autrement en santé qui font de la fièvre et présentent une neutropénie, la plupart des cas étant causés par une infection virale. Les enfants âgés de six mois à 18 ans qui ont l'air bien, ne souffrent pas d'un cancer, sont considérés comme immunocompétents et présentent un premier épisode de neutropénie, sans autres facteurs de risque, n'ont généralement pas besoin d'antibiotiques empiriques. Cependant, une évaluation approfondie est indiquée, y compris une anamnèse et un examen physique complets, de même qu'une hémoculture lorsque la numération absolue des neutrophiles est inférieure à 0,5 × 109/L. Il est recommandé d'assurer un suivi étroit, de reprendre l'hémogramme et de donner des conseils préventifs stricts.
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Affiliation(s)
- Marie-Pier Lirette
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Nicola Wright
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Evelyne D Trottier
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Carolyn E Beck
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
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10
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Lirette MP, Wright N, Trottier ED, Beck CE. Management of febrile neutropenia in immunocompetent children and youth. Paediatr Child Health 2023; 28:324-330. [PMID: 37484042 PMCID: PMC10362957 DOI: 10.1093/pch/pxac127] [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: 12/18/2021] [Accepted: 08/13/2022] [Indexed: 07/25/2023] Open
Abstract
Febrile neutropenia is a common clinical presentation in children that can be associated with invasive bacterial infection (IBI). However, in otherwise healthy children and youth with fever and neutropenia, the risk for IBI is low, with most cases being caused by viral infections. Well-appearing, non-oncologic, and presumed immunocompetent children aged 6 months to 18 years experiencing a first episode of neutropenia, with no additional risk factors, typically do not require empiric antibiotics. However, a thorough assessment, including complete history and physical exam, is indicated, and a blood culture should be performed when the absolute neutrophil count is <0.5 × 109/L. Close follow-up, a repeat complete blood count, and strong anticipatory guidance are recommended.
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Affiliation(s)
- Marie-Pier Lirette
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Nicola Wright
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Evelyne D Trottier
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Carolyn E Beck
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
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11
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Prince RD, Blumenthal JA, Geva A. Examining the Evidence for Escalating Antimicrobial Regimens in Febrile Oncology and Hematopoietic Stem Cell Transplant Patients Admitted to the PICU: An Observational Study. Pediatr Crit Care Med 2023; 24:e292-e296. [PMID: 37036203 DOI: 10.1097/pcc.0000000000003238] [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] [Indexed: 04/11/2023]
Abstract
OBJECTIVES To examine whether escalating antimicrobial treatment in pediatric oncology and hematopoietic cell transplantation (HSCT) patients admitted to the PICU is supported by culture data or affects patient outcomes. DESIGN Retrospective cross-sectional study. SETTING Quaternary care PICU. PATIENTS Patients younger than 18 years old who were admitted to the PICU at Boston Children's Hospital from 2012 to 2017 with a diagnosis of cancer or who had received HSCT and who had suspected sepsis at the time of PICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 791 PICU admissions for 544 patients that met inclusion criteria, 71 (9%) had escalation of antimicrobial therapy. Median Pediatric Logistic Organ Dysfunction (PELOD) score was higher in the escalation group (4 vs 3; p = 0.01). There were 14 admissions (20%) with a positive culture in the escalation group and 110 (15%) in the no escalation group ( p = 0.31). In the escalation group, there were only 2 (3%) cultures with organisms resistant to the initial antimicrobial regimen, compared with 28 (4%) cultures with resistant organisms in the no escalation group ( p = 1). Mortality in the escalation group was higher (17%) compared with the nonescalation group (5%; p < 0.001). The escalation group had more acute kidney injury (AKI) (25%) during treatment compared with the no escalation group (15%; p = 0.04), although this difference was not statistically significant when controlling for age, neutropenia, and PELOD-2 score (odds ratio, 1.75; 95% CI, 0.95-3.08; p = 0.06). CONCLUSIONS Few patients who had escalation of antimicrobials proved on culture data to have an organism resistant to the initial antimicrobials, and more patients developed AKI during escalated treatment. While the escalation group likely represents a sicker population, whether some of these patients would be safer without escalation of antimicrobial therapy warrants further study.
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Affiliation(s)
- Remi D Prince
- Tufts University School of Medicine, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer A Blumenthal
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Alon Geva
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
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12
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Lehrnbecher T, Robinson PD, Ammann RA, Fisher B, Patel P, Phillips R, Beauchemin MP, Carlesse F, Castagnola E, Davis BL, Elgarten CW, Groll AH, Haeusler GM, Koenig C, Santolaya ME, Tissing WJ, Wolf J, Alexander S, Hu H, Dupuis LL, Sung L. Guideline for the Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients: 2023 Update. J Clin Oncol 2023; 41:1774-1785. [PMID: 36689694 PMCID: PMC10022858 DOI: 10.1200/jco.22.02224] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To update a clinical practice guideline (CPG) for the empiric management of fever and neutropenia (FN) in pediatric patients with cancer and hematopoietic cell transplantation recipients. METHODS The International Pediatric Fever and Neutropenia Guideline Panel reconvened to conduct the second update of this CPG. We updated the previous systematic review to identify new randomized controlled trials (RCTs) evaluating any strategy for the management of FN in pediatric patients. Using the Grading of Recommendations Assessment, Development and Evaluation framework, evidence quality was classified as high, moderate, low, or very low. The panel updated recommendations related to initial management, ongoing management, and empiric antifungal therapy. Changes from the 2017 CPG were articulated, and good practice statements were considered. RESULTS We identified 10 new RCTs in addition to the 69 RCTs identified in previous FN CPGs to inform the 2023 FN CPG. Changes from the 2017 CPG included two conditional recommendations regarding (1) discontinuation of empiric antibacterial therapy in clinically well and afebrile patients with low-risk FN if blood cultures remain negative at 48 hours despite no evidence of marrow recovery and (2) pre-emptive antifungal therapy for invasive fungal disease in high-risk patients not receiving antimold prophylaxis. The panel created a good practice statement to initiate FN CPG-consistent empiric antibacterial therapy as soon as possible in clinically unstable febrile patients. CONCLUSION The updated FN CPG incorporates important modifications on the basis of recently published trials. Future work should focus on addressing knowledge gaps, improving CPG implementation, and measuring the impact of CPG-consistent care.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany
| | | | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
- Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Brian Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Priya Patel
- Pediatric Oncology Group of Ontario, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
| | - Robert Phillips
- Department of Haematology and Oncology, Leeds Teaching Hospital, NHS Trust, Leeds, United Kingdom
| | - Melissa P. Beauchemin
- Columbia University/Herbert Irving Cancer Center, Columbia University School of Nursing, New York, NY
| | - Fabianne Carlesse
- Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | | | - Andreas H. Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany
| | - Gabrielle M. Haeusler
- Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Center, Melbourne, Australia
- NHMRC National Center for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
- Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Maria E. Santolaya
- Department of Pediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joshua Wolf
- Division of Infectious Disease, St Jude Children's Research Hospital, Memphis, TN
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Helen Hu
- Pediatric Oncology Group of Ontario, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - L. Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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13
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Bochennek K, Hogardt M, Lehrnbecher T. Immune signatures, testing, and management of febrile neutropenia in pediatric cancer patients. Expert Rev Clin Immunol 2023; 19:267-277. [PMID: 36635981 DOI: 10.1080/1744666x.2023.2168646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Infectious complications, particularly invasive bacterial and fungal infections, are still a major cause of morbidity in pediatric cancer patients and are associated with significant mortality. Over the last few years, there has been much effort in defining risk groups to tailor antimicrobial therapy, and in establishing pediatric-specific guidelines for antimicrobial strategies. AREAS COVERED This review provides a critical overview of defining risk groups for infection, diagnostic work-up, antimicrobial prophylaxis, empirical therapy, and treatment of established infections. EXPERT OPINION To date, no generalizable risk prediction model has been established for pediatric cancer patients. There is growing interest in defining the impact of the individual genetic background on infectious complications. New diagnostic tools have been developed over the last few years, but they need to be validated in pediatric cancer patients. International, pediatric-specific guidelines for antimicrobial prophylaxis, empirical therapy, and treatment of established infections have recently been published and will harmonize antimicrobial strategies in the future.
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Affiliation(s)
- Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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14
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Moortgat J, Boulanger C, Chatzis O. Safety of reducing antibiotic use in children with febrile neutropenia: A systematic review. Pediatr Hematol Oncol 2022; 39:707-723. [PMID: 35465847 DOI: 10.1080/08880018.2022.2055245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Febrile neutropenia is the most frequent complication in children treated with chemotherapy. Nevertheless, neutropenic children are a very heterogeneous group and invasive bacterial infections concern a minority of patients. Reducing antibiotics would bring many benefits. Yet, we can only explore this strategy if the safety of children is preserved. The main aims of this review were to study the safety and effectiveness of reducing antibiotic use in children with febrile neutropenia in terms of duration, route of administration (oral versus intravenous) and narrowing of antimicrobial spectrum. Cochrane Library, Pubmed and Embase were searched for relevant articles until February 2020. We have included all articles describing controlled trials written in French or in English. The risk of bias was assessed with ROB-2 (Cochrane Handbook for Systematic Reviews of Interventions Version 6.0. 2019, Chap. 8) or ROBINS-1 (Cochrane Handbook for Systematic Reviews of Interventions Version 6.0. 2019, Chap. 25). On 2351 articles, the systematic research retained 13 studies. Nine were used for a meta-analysis comparing oral versus intravenous treatment. We found no pediatric studies concerning de-escalation of empiric broad-spectrum antibiotics. No publication biases were found and almost all of the selected studies were at low risk or with some concern for bias. In comparing oral versus intravenous treatment and early cessation versus continuing antibiotics when no infection is proven, we found no difference in terms of safety (mortality and admission in intensive care unit) and efficacy (need of readmission/antibiotic modification/recurrence of fever). It seems safe and effective to provide oral treatment in low-risk febrile neutropenia and to stop antibiotics when no bacterial infection is proven. Spectrum reduction remains an important topic in pediatric research.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2022.2055245.
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Affiliation(s)
- Jennifer Moortgat
- Paediatric Infectious Diseases, Department of Paediatrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Cécile Boulanger
- Paediatric Hemato-Oncology, Department of Paediatrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Olga Chatzis
- Paediatric Infectious Diseases, Department of Paediatrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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15
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Karaman S, Kebudi R, Kizilocak H, Karakas Z, Demirag B, Evim MS, Yarali N, Kaya Z, Karagun BS, Aydogdu S, Caliskan U, Ayhan AC, Bahadir A, Cakir B, Guner BT, Albayrak C, Karapinar DY, Kazanci EG, Unal E, Turkkan E, Akici F, Bor O, Vural S, Yilmaz S, Apak H, Baytan B, Tahta NM, Güzelkucuk Z, Kocak U, Antmen B, Tokgöz H, Fisgin T, Özdemir N, Gunes AM, Vergin C, Unuvar A, Ozbek N, Tugcu D, Bay SB, Tanyildiz HG, Celkan T. Central Nervous System Fungal Infections in Children With Leukemia and Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Multicenter Study. J Pediatr Hematol Oncol 2022; 44:e1039-e1045. [PMID: 36036521 DOI: 10.1097/mph.0000000000002499] [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] [Received: 09/05/2021] [Accepted: 05/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central nervous system fungal infections (CNSFI) are seen in patients with hematologic malignancies and have high morbidity and mortality. Because of their rarity, there is limited data on CNSFI in children with no established treatment protocols or guidelines. MATERIALS AND METHODS In this multicenter retrospective study, 51 pediatric patients with leukemia, 6 of whom had undergone bone marrow transplantation, with proven or probable CNSFI were evaluated. Fungal infections were defined as proven or probable based on European Organisation for Research and Treatment of Cancer criteria. Proven CNSFI was diagnosed by appropriate central nervous system (CNS) imaging or tissue sample findings in combination with positive microbiological results of cerebrospinal fluid. A positive culture, microscopic evidence of hyphae, a positive result of the galactomannan assays are defined as positive microbiological evidence. Probable CNSFI was defined as appropriate CNS imaging findings together with proven or probable invasive fungal infections at another focus without CNS when there is no other explanatory condition. Data was collected by using the questionnaire form (Supplemental Digital Content 1, http://links.lww.com/JPHO/A541 ). RESULTS Seventeen patients had proven, 34 patients had probable CNSFI. Headaches and seizures were the most common clinical findings. The median time between the onset of fever and diagnosis was 5 days. The most common fungal agent identified was Aspergillus . Sixteen patients received single-agent, 35 received combination antifungal therapy. Surgery was performed in 23 patients. Twenty-two patients (43%) died, 29 of the CNSFI episodes recovered with a 20% neurological sequelae. CONCLUSION CNSFIs should be considered in the differential diagnosis in patients with leukemia and refractory/recurrent fever, headache, neurologicalocular symptoms, and a radiologic-serological evaluation should be performed immediately. Early diagnosis and prompt management, both medical and surgical, are essential for improving clinical outcomes.
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Affiliation(s)
- Serap Karaman
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Rejin Kebudi
- Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute
| | - Hande Kizilocak
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
| | - Zeynep Karakas
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Bengu Demirag
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Melike S Evim
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Nese Yarali
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Zuhre Kaya
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Gazi University, Ankara
| | - Barbaros S Karagun
- Division of Pediatric Hematology-Oncology, Acibadem Adana Hospital, Adana
| | - Selime Aydogdu
- Division of Pediatric Hematology-Oncology, Altinbas University Bahcelievler Medical Park Hospital
| | - Umran Caliskan
- Division of Pediatric Hematology-Oncology, Meram University Faculty of Medicine, Konya
| | - Aylin C Ayhan
- Division of Pediatric Hematology-Oncology, Medeniyet University, Faculty of Medicine
| | - Aysenur Bahadir
- Division of Pediatric Hematology-Oncology, Karadeniz Technical University, Faculty of Medicine, Trabzon
| | - Betul Cakir
- Division of Pediatric Hematology-Oncology, Bezmiâlem Vakif University
| | - Burcak T Guner
- Division of Pediatric Hematology-Oncology, Izmir University of Health Sciences Tepecik Training and Research Hospital
| | - Canan Albayrak
- Division of Pediatric Hematology-Oncology, Ondokuz Mayis University, Faculty of Medicine, Samsun
| | - Deniz Y Karapinar
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Ege University
| | - Elif G Kazanci
- Division of Pediatric Hematology-Oncology, Health Sciences University Bursa High Specialist Training and Research Hospital, Bursa
| | - Ekrem Unal
- Division of Pediatric Hematology-Oncology, Erciyes University Faculty of Medicine, Kayseri
| | - Emine Turkkan
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Okmeydani Training and Research Hospital
| | - Ferhan Akici
- Division of Pediatric Hematology-Oncology, University of Health Science Kanuni Sultan Süleyman Research and Training Hospital
| | - Ozcan Bor
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Sema Vural
- Division of Pediatric Hematology-Oncology, Health Sciences University Istanbul Sariyer Hamidiye Etfal Health Practice and Research Center, Istanbul
| | - Sebnem Yilmaz
- Division of Pediatric Hematology-Oncology, Dokuz Eylul University Faculty of Medicine, Izmir
| | - Hilmi Apak
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
| | - Birol Baytan
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Neryal M Tahta
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Zeliha Güzelkucuk
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Ulker Kocak
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Gazi University, Ankara
| | - Bulent Antmen
- Division of Pediatric Hematology-Oncology, Acibadem Adana Hospital, Adana
| | - Huseyin Tokgöz
- Division of Pediatric Hematology-Oncology, Meram University Faculty of Medicine, Konya
| | - Tunc Fisgin
- Division of Pediatric Hematology-Oncology, Altinbas University Bahcelievler Medical Park Hospital
| | - Nihal Özdemir
- Division of Pediatric Hematology-Oncology, University of Health Science Kanuni Sultan Süleyman Research and Training Hospital
| | - Adalet M Gunes
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Canan Vergin
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Aysegul Unuvar
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Namik Ozbek
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Deniz Tugcu
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Sema B Bay
- Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute
| | - Hikmet G Tanyildiz
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Tiraje Celkan
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
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Infections during Non-Neutropenic Episodes in Pediatric Cancer Patients—Results from a Prospective Study in Two Major Large European Cancer Centers. Antibiotics (Basel) 2022; 11:antibiotics11070900. [PMID: 35884154 PMCID: PMC9311840 DOI: 10.3390/antibiotics11070900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 12/04/2022] Open
Abstract
Whereas the clinical approach in pediatric cancer patients with febrile neutropenia is well established, data on non-neutropenic infectious episodes are limited. We therefore prospectively collected over a period of 4 years of data on all infectious complications in children treated for acute lymphoblastic or myeloid leukemia (ALL or AML) and non-Hodgkin lymphoma (NHL) at two major pediatric cancer centers. Infections were categorized as fever of unknown origin (FUO), and microbiologically or clinically documented infections. A total of 210 patients (median age 6 years; 142 ALL, 23 AML, 38 NHL, 7 leukemia relapse) experienced a total of 776 infectious episodes (571 during neutropenia, 205 without neutropenia). The distribution of FUO, microbiologically and clinically documented infections, did not significantly differ between neutropenic and non-neutropenic episodes. In contrast to neutropenic patients, corticosteroids did not have an impact on the infectious risk in non-neutropenic children. All but one bloodstream infection in non-neutropenic patients were due to Gram-positive pathogens. Three patients died in the context of non-neutropenic infectious episodes (mortality 1.4%). Our results well help to inform clinical practice guidelines in pediatric non-neutropenic cancer patients presenting with fever, in their attempt to safely restrict broad-spectrum antibiotics and improve the quality of life by decreasing hospitalization.
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17
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Wattier RL, Esbenshade AJ. From "More is Better" to "Less is More": A Commentary on Antimicrobial Use in Pediatric Oncology. J Pediatric Infect Dis Soc 2022; 11:229-238. [PMID: 35099542 DOI: 10.1093/jpids/piab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/14/2022]
Abstract
Reducing avoidable antimicrobial exposure to pediatric patients with cancer is achievable and necessary to promote optimal short- and long-term outcomes. Multiple evidence-based practices are already well established but should be more consistently implemented. Important opportunities exist to further improve the evidence to guide selective antimicrobial use in pediatric oncology.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| | - Adam J Esbenshade
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University, Nashville, Tennessee, USA
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18
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Mantadakis E, Kopsidas I, Coffin S, Dimitriou G, Gkentzi D, Hatzipantelis E, Kaisari A, Kattamis A, Kourkouni E, Papachristidou S, Papakonstantinou E, Polychronopoulou S, Roilides E, Spyridis N, Tsiodras S, Tsolia MN, Tsopela GC, Zaoutis T, Tragiannidis A. A national study of antibiotic use in Greek pediatric hematology oncology and bone marrow transplant units. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e71. [PMID: 36483391 PMCID: PMC9726537 DOI: 10.1017/ash.2022.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We surveyed antimicrobials used in Greek pediatric hematology-oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients. DESIGN Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017. INTERVENTION In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated. SETTING Five of the 6 PHO units in Greece and the single pediatric BMT unit participated. PARTICIPANTS Admitted children in each unit who received the first 15 new antibiotic courses each month. RESULTS Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children's hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008). CONCLUSIONS We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.
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Affiliation(s)
- Elpis Mantadakis
- Democritus University of Thrace Faculty of Medicine, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ioannis Kopsidas
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Susan Coffin
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Gabriel Dimitriou
- Patras Medical School, University General Hospital of Patras, Patra, Greece
| | - Despoina Gkentzi
- Patras Medical School, University General Hospital of Patras, Patra, Greece
| | - Emmanouel Hatzipantelis
- Children & Adolescent Hematology–Oncology Unit, Second Pediatric Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Kaisari
- Stem Cell Transplant Unit, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Eleni Kourkouni
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | | | | | - Sophia Polychronopoulou
- Department of Pediatric Hematology–Oncology (T.A.O.), Aghia Sophia Children’s Hospital, Athens, Greece
| | - Emmanuel Roilides
- Third Department of Pediatrics, Aristotle University of Thessaloniki, Hipppokration General Hospital, Thessaloniki, Greece
| | - Nikos Spyridis
- Infectious Diseases Unit, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Maria N. Tsolia
- Infectious Diseases Unit, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Theoklis Zaoutis
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
- Infectious Diseases Unit, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Athanasios Tragiannidis
- Children & Adolescent Hematology–Oncology Unit, Second Pediatric Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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19
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Rider E, Ligon JA, Voskertchian A, Milstone AM, Toltzis P. Sampling Multiple Catheter Lumens to Improve Detection of Bloodstream Infection in Pediatric Oncology Patients. J Pediatr Hematol Oncol 2022; 44:e518-e520. [PMID: 34978782 PMCID: PMC8840984 DOI: 10.1097/mph.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Erica Rider
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - John A. Ligon
- Department of Oncology, Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Annie Voskertchian
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M. Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Philip Toltzis
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH
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20
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Dessie AS, Lanning M, Nichols T, Delgado EM, Hart LS, Agrawal AK. Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care 2022; 38:e259-e263. [PMID: 32941363 DOI: 10.1097/pec.0000000000002241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.
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Affiliation(s)
| | - Miranda Lanning
- New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Tristan Nichols
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | | | - Anurag K Agrawal
- Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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21
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Rieder MJ, Elzagallaai AA. Pharmacogenomics in Children. Methods Mol Biol 2022; 2547:569-593. [PMID: 36068477 DOI: 10.1007/978-1-0716-2573-6_20] [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] [Indexed: 06/15/2023]
Abstract
Historically genetics has not been considered when prescribing drugs for children. However, it is clear that genetics are not only an important determinant of disease in children but also of drug response for many important drugs that are core agents used in the therapy of common problems in children. Advances in therapy and in the ethical construct of children's research have made pharmacogenomic assessment for children much easier to pursue. It is likely that pharmacogenomics will become part of the therapeutic decision-making process for children, notably in areas such as childhood cancer where weighing benefits and risks of therapy is crucial.
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Affiliation(s)
- Michael J Rieder
- Division of Paediatric Clinical Pharmacology, Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
| | - Abdelbaset A Elzagallaai
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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22
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Ahmad AH, Brown BD, Andersen CR, Mahadeo KM, Petropolous D, Cortes JA, Razvi S, Gardner MK, Ewing LJ, Mejia RE. Retrospective Review of Flexible Bronchoscopy in Pediatric Cancer Patients. Front Oncol 2022; 11:770523. [PMID: 34970488 PMCID: PMC8712312 DOI: 10.3389/fonc.2021.770523] [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: 09/04/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022] Open
Abstract
The use of flexible bronchoscopy (FB) with bronchoalveolar lavage (BAL) to diagnose and manage pulmonary complications has been shown to be safe in adult cancer patients, but whether its use is safe in pediatric cancer patients remains unclear. Thus, to describe the landscape of FB outcomes in pediatric cancer patients and to help define the populations most likely to benefit from the procedure, we undertook a retrospective review of FBs performed in patients younger than 21 years treated at our institution from 2002 to 2017. We found that a greater volume of total fluid instilled during BAL was significantly associated with increased probabilities of positive BAL culture (p=0.042), positive bacterial BAL culture (p=0.037), and positive viral BAL culture (p=0.0496). In more than half of the FB cases, findings resulted in alterations in antimicrobial treatment. Our study suggests that for pediatric cancer patients, FB is safe, likely provides diagnostic and/or therapeutic benefits, and has implications for treatment decisions.
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Affiliation(s)
- Ali H Ahmad
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Brandon D Brown
- Pediatric Oncology Fellowship Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Clark R Andersen
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy and CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Demetrios Petropolous
- Pediatric Stem Cell Transplantation and Cellular Therapy and CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - José A Cortes
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Shehla Razvi
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mary Katherine Gardner
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Linette J Ewing
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rodrigo E Mejia
- Pediatric Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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23
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Pulcini CD, Lentz S, Saladino RA, Bounds R, Herrington R, Michaels MG, Maurer SH. Emergency management of fever and neutropenia in children with cancer: A review. Am J Emerg Med 2021; 50:693-698. [PMID: 34879488 DOI: 10.1016/j.ajem.2021.09.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery and Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine and Critical Care, Department of Surgery and Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States of America
| | - Richard A Saladino
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Ramsey Herrington
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Marian G Michaels
- Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Scott H Maurer
- Division of Hematology/Oncology, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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24
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Cennamo F, Masetti R, Largo P, Argentiero A, Pession A, Esposito S. Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy. CHILDREN 2021; 8:children8121086. [PMID: 34943282 PMCID: PMC8700030 DOI: 10.3390/children8121086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.
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Affiliation(s)
- Federica Cennamo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Prisca Largo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704-790
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25
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Cross SJ, Morton TH, Wolf J. Epidemiology, Diagnosis, and Treatment of Clostridioides difficile Infection in Immunocompromised Children. J Pediatric Infect Dis Soc 2021; 10:S46-S51. [PMID: 34791397 PMCID: PMC8824809 DOI: 10.1093/jpids/piab078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Clostridioides difficile infection is very common in immunocompromised children. Management is confounded by frequent asymptomatic colonization, multiple alternative etiologies for gastrointestinal symptoms, and high rates of relapse. Important considerations include indications for testing, appropriate choice of diagnostic tests, antibiotic therapy for initial and subsequent episodes, and primary and secondary prevention.
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Affiliation(s)
- Shane J Cross
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Theodore H Morton
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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26
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Shimamoto Y, Verstegen RHJ, Mizuno T, Schechter T, Allen U, Ito S. Population pharmacokinetics of vancomycin in paediatric patients with febrile neutropenia and augmented renal clearance: development of new dosing recommendations. J Antimicrob Chemother 2021; 76:2932-2940. [PMID: 34480578 DOI: 10.1093/jac/dkab302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/23/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the influence of augmented renal clearance (ARC) on vancomycin clearance and provide dosage recommendations for paediatric patients with febrile neutropenia following HSCT. METHODS A population pharmacokinetic analysis was performed based on a two-compartment model structure using a non-linear mixed-effect modelling approach. Monte Carlo simulations were conducted as a target attainment analysis of AUC between 400 mg·h/L and 650 mg·h/L for MRSA at an MIC of 1 mg/L. RESULTS A total of 165 paediatric patients and 276 vancomycin serum concentrations were analysed in this study. Age, body weight, estimated glomerular filtration rate (eGFR) and fever (≥38.0°C) were identified as factors that significantly influenced vancomycin clearance. The median eGFR of the population was 143 mL/min/1.73 m2 and 34% of patients showed an eGFR ≥160 mL/min/1.73 m2, which may be classified as ARC. Our simulations showed that current dosing recommendations result in poor target attainment. In particular, children aged 6 months old to 6 years old with ARC require an initial vancomycin dose up to 35%-65% higher than the current dosing guidelines. CONCLUSIONS ARC is frequently observed in paediatric patients with post-HSCT febrile neutropenia, resulting in a significant increase in vancomycin clearance. We propose a vancomycin dosing strategy for children with febrile neutropenia following HSCT based on eGFR, age, weight and body temperature.
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Affiliation(s)
- Yuko Shimamoto
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tal Schechter
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Hematology/Oncology/BMT, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Upton Allen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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27
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Alali M, David MZ, Ham SA, Danziger-Isakov L, Pisano J. Febrile Neutropenia Syndromes in Children: Risk Factors and Outcomes of Primary, Prolonged, and Recurrent Fever. J Pediatr Hematol Oncol 2021; 43:e962-e971. [PMID: 34133386 DOI: 10.1097/mph.0000000000002221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The approach to recurrent febrile neutropenia (FN) in children with cancer has not been sufficiently addressed and was cited as a research gap in the International Pediatric Fever and Neutropenia (IPFNP) Guideline 2017. METHODS Retrospective medical record review for all pediatric cancer patients with a diagnosis of FN was performed. Variables were collected at 2 different time sets (at day 1 and day 4 of presentation). Three FN syndromes have been defined based on the duration and time course of the fever: (1) primary: fever resolved before 96 hours and did not follow with recurrent fever; (2) prolonged fever: episodes failing to defervesce after at least 96 hours of antibacterial therapy; (3) recurrent fever: a new episode of fever >72 hours after resolution of the initial fever when a patient remained neutropenic and on antibiotics or if a fever developed within 1 week after antibiotic discontinuation. These entities were compared with define risk factors and adverse outcomes associated with recurrent fever. RESULTS A total of 633 FN episodes (FNEs) were identified in 268 patients. Each FNE was classified as primary (n=453, 71.5%), prolonged (n=119, 18.7%), or recurrent (n=61, 9.7%). In multivariable analysis, acute myelogenous leukemia (odds ratio [OR]=4.6, 95% confidence interval [CI]: 2.95-7.24), allogeneic stem cell transplant (SCT) (OR=4.9, 95% CI: 2.61-7.35), absolute lymphocyte count <300/mm3 (OR=3.8, 95% CI: 1.30-5.02), prior neutropenia of ≥10 days, (OR=3.95, 95% CI: 1.70-5.93) and hypotension (OR=3.65, 95% CI: 1.30-5.86) on day 1 of presentation were all associated with an increased risk of recurrent fever when compared with primary fever. In subset analysis for only the high-risk FN group, hypotension (OR=3.2, 95% CI: 1.80-4.96), prior neutropenia ≥10 days (OR=2.55, 95% CI: 1.40-6.22), and absolute lymphocyte count <300/mm3 at presentation (OR=2.6, P=0.03, 95% CI: 2.65-7.12) were associated with an increased risk of recurrent fever when compared with high-risk FN not developing recurrent fever. Allogeneic SCT (OR=5.9, 95% CI: 2.65-7.12) and prior neutropenia ≥10 days (OR=2.11, 95% CI: 1.25-9.32) were significantly associated with recurrent fever when compared with prolonged fever. Invasive fungal disease was a more common etiology with recurrent fever compared with primary and prolonged fever (P=0.001 and 0.01, respectively). Recurrent fever episodes were more likely to be admitted to the pediatric intensive care unit (OR=3, 95% CI: 1.27-6.23) and had a higher 30-day mortality (OR=8, 95% CI: 1.87-71.85) when compared with primary fever. CONCLUSIONS Knowledge of risk factors for recurrent fever may enable the early detection infection-related complications of this high-risk group, and possible improved approaches to treatment resulting in decreased morbidity and mortality.
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Affiliation(s)
| | - Michael Z David
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA
| | - Sandra A Ham
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Immunocompromised Host Infectious Disease Cincinnati, OH
| | - Jennifer Pisano
- Medicine, Division of Infectious Diseases, University of Chicago Medicine
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28
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Arıkan K, Karadağ-Oncel E, Aytac S, Cengiz AB, Duygu Cetinkaya F, Kara A, Ceyhan M. The use of serum endothelial adhesion molecules in pediatric patients with leukemia with febrile neutropenia to predict bacteremia. Cytokine 2021; 148:155692. [PMID: 34500368 DOI: 10.1016/j.cyto.2021.155692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/01/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Febrile neutropenia (FN) represents a life-threatening complication in hematological malignancies. We aimed to analyze the utility of soluble vascular cell adhesion molecule 1 (sVCAM-1), intercellular adhesion molecule 1 (sICAM-1), vascular endothelial growth factor (VEGF) levels compared with C-reactive protein (CRP) and procalcitonin (PCT) during febrile neutropenia episodes of pediatric patients with leukemia. METHODS Two plasma samples, on day 0 (initial of episode) and day 3 (48-72 h after episode), for VCAM-1, ICAM-1 and VEGF, CRP and PCT were prospectively collected concomitantly during each febrile neutropenic episode between December 2016 and December 2017. The primary outcome was bacteremia and the secondary outcome was intensive care unit (ICU) admission. RESULTS Twenty-two (28.6%) acute lymphoblastic lymphoma (ALL), seventeen (22.1%) acute myeloblastic lymphoma (AML) patients and thirty-eight (49.3%) control patients with no known underlying disease or fever were included in this study. Of the 39 patients; 16 (41%) had bacteremia. Mean serum sVCAM1 and sICAM1 levels were significantly higher in control group, compared to FN patients (p < 0.001). Mean serum sVCAM2 level was significantly higher in FN patients with bacteremia compared to FN patients without bacteremia (144.97 ± 70.35 pg/mL vs 85.45 ± 53.76 pg/mL, p = 0.022). Mean sVCAM1 and 2 levels were higher in FN patients with ICU admission. In this study, we found that sVCAM-1 and VEGF, when combined to CRP and PCT, could predict gram-negative bacteremia in FN episodes of pediatric hematological malignancy. CONCLUSION Serum endothelial adhesion molecules, excluding sVCAM-1, cannot predict bacteremia and ICU admission alone in FN patients; but may be associated with clinical outcome when used with PCT and CRP.
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Affiliation(s)
- Kamile Arıkan
- Health Sciences University, Izmir Behcet Uz Children's Hospital, Department of Pediatric Infectious Diseases, Izmir, Turkey.
| | - Eda Karadağ-Oncel
- Health Sciences University, Izmir Tepecik Research and Training Hospital, Department of Pediatric Infectious Diseases, Izmir, Turkey
| | - Selin Aytac
- Hacettepe University Faculty of Medicine, Pediatric Hematology Unit, Ankara, Turkey
| | - Ali Bülent Cengiz
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases, Ankara, Turkey
| | | | - Ates Kara
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases, Ankara, Turkey
| | - Mehmet Ceyhan
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases, Ankara, Turkey
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Wu NL, Hingorani S. Outcomes of kidney injury including dialysis and kidney transplantation in pediatric oncology and hematopoietic cell transplant patients. Pediatr Nephrol 2021; 36:2675-2686. [PMID: 33411070 DOI: 10.1007/s00467-020-04842-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/10/2020] [Accepted: 10/22/2020] [Indexed: 01/26/2023]
Abstract
Pediatric oncology and hematopoietic cell transplant (HCT) patients are susceptible to both acute kidney injury (AKI) and chronic kidney disease (CKD). The etiologies of AKI vary but include tumor infiltration, radiation, drug-induced toxicity, and fluid and electrolyte abnormalities including tumor lysis syndrome. HCT patients can also have additional complications such as sinusoidal obstructive syndrome, graft-versus-host disease, or thrombotic microangiopathy. For patients with severe AKI requiring dialysis, multiple modalities can be used successfully, although continuous kidney replacement therapy (CKRT) is often the principal modality for critically ill patients. While increasing numbers of pediatric cancer and HCT patients are now surviving long term, they remain at risk for a number of chronic medical conditions, including CKD. Certain high-risk patients, due to underlying risk factors or treatment-related complications, eventually develop kidney failure and may require kidney replacement therapies. Management of co-morbidities and complications associated with kidney failure, including use of erythropoietin for anemia and potential need for ongoing cancer-related treatment while on dialysis, is an additional consideration in this patient population. Kidney transplantation can be successfully performed in pediatric cancer survivors, although additional features such as specific cancer diagnosis and duration of remission should be considered.
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Affiliation(s)
- Natalie L Wu
- Department of Pediatrics, Division of Hematology/Oncology, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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Trends in bacterial bloodstream infections and resistance in immuno-compromised patients with febrile neutropenia: a retrospective analysis. Eur J Pediatr 2021; 180:2921-2930. [PMID: 33835249 DOI: 10.1007/s00431-021-04056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Bacterial infections remain a major cause of morbidity and mortality in immunocompromised children. From the onset of fever, an early administration of broad-spectrum antibiotics is begun; this strategy could induce emergence of multi-drug resistant bacteria (MDR). We describe the incidence and microbiological spectrum, including MDR bacteria of bacterial documented blood-stream infections (BSI) in immunocompromised children. A retrospective, descriptive study was conducted in a tertiary referral centre in France from January 2014 to December 2017. Our cohort included a large scale of patients with febrile neutropenia: haematological and oncological malignancies, haematopoietic stem cell transplantations, severe combined immunodeficiency syndromes. BSI were defined by positive blood culture samples associated with fever. Among 760 febrile neutropenia episodes in 7301 admitted patients, we identified 310 documented BSI with a mean of 7.4 BSI/1000 patient bed days. Only 2.9% BSIs were caused by MDR bacteria, none vancomycin resistant. Coagulase-negative staphylococci were identified in 49.7% BSI and Staphylococcus aureus caused 6.5% infections. Gram-negative bacilli accounted for 21.6% of isolated bacteria, Pseudomonas for 4.8%. The incidence of BSI annually decreased by 0.75% (p = 0.002).Conclusion: With a step-down strategy at 48 h of initial broad-spectrum antibiotic therapy, we reported a low number of MDR bacteria, no deaths related to BSI. What is Known: • Bacterial bloodstream infections are a leading cause of morbidity and mortality in immunocompromised children • Multi-drug resistant bacteria are emerging worldwide. What is New: • Initial broad-spectrum antibiotic therapy with a step-down strategy at 48 h: no deaths related to bloodstream infections with a low number of resistant bacteria. • Parental and nurse stewardship to decrease bloodstream infections incidence with a drop of staphylococcal infections.
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Gonzalez ML, Aristizabal P, Loera-Reyna A, Torres D, Ornelas-Sánchez M, Nuño-Vázquez L, Aguilera M, Sánchez A, Romano M, Rivera-Gómez R, Relyea G, Friedrich P, Caniza MA. The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico. JCO Glob Oncol 2021; 7:659-670. [PMID: 33974443 PMCID: PMC8162497 DOI: 10.1200/go.20.00578] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico. METHODS We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III. RESULTS Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001). CONCLUSION Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.
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Affiliation(s)
- Miriam L Gonzalez
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Paula Aristizabal
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of California San Diego, La Jolla, CA.,Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Population Sciences, Disparities and Community Engagement, Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Adriana Loera-Reyna
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Dara Torres
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Mario Ornelas-Sánchez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Laura Nuño-Vázquez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Marco Aguilera
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Alicia Sánchez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Mitzy Romano
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Rebeca Rivera-Gómez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - George Relyea
- School of Public Health, University of Memphis, Memphis, TN
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Miguela A Caniza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
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Pediatric onco-nephrology: time to spread the word : Part I: early kidney involvement in children with malignancy. Pediatr Nephrol 2021; 36:2227-2255. [PMID: 33245421 DOI: 10.1007/s00467-020-04800-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/28/2020] [Accepted: 09/25/2020] [Indexed: 12/29/2022]
Abstract
Onco-nephrology has been a growing field within the adult nephrology scope of practice. Even though pediatric nephrologists have been increasingly involved in the care of children with different forms of malignancy, there has not been an emphasis on developing special expertise in this area. The fast pace of discovery in this field, including the development of new therapy protocols with their own kidney side effects and the introduction of the CD19-targeted chimeric antigen receptor T cell (CAR-T) therapy, has introduced new challenges for general pediatric nephrologists because of the unique effects of these treatments on the kidney. Moreover, with the improved outcomes in children receiving cancer therapy come an increased number of survivors at risk for chronic kidney disease related to both their cancer diagnosis and therapy. Therefore, it is time for pediatric onco-nephrology to take its spot on the expanding subspecialties map in pediatric nephrology.
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Melgar M, Reljic T, Barahona G, Camacho K, Chang A, Contreras J, Espinoza D, Estripeaut D, Gamero M, Luque M, Mentor G, Zacasa P, Homsi M, Caniza MA, Kumar A, Mukkada S. Guidance Statement for the Management of Febrile Neutropenia in Pediatric Patients Receiving Cancer-Directed Therapy in Central America and the Caribbean. JCO Glob Oncol 2021; 6:508-517. [PMID: 32216650 PMCID: PMC7124939 DOI: 10.1200/jgo.19.00329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Mario Melgar
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Tea Reljic
- Department of Internal Medicine, University of South Florida, Tampa, FL
| | | | - Kattia Camacho
- Hospital Nacional de Niños Dr. Carlos Sáenz Herrera, San José, Costa Rica
| | - Alicia Chang
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Johanny Contreras
- Hospital Infantil Dr Robert Reid Cabral, Santo Domingo, Dominican Republic
| | - Darrell Espinoza
- Hospital Infantil Manuel de Jesus Rivera "La Mascota," Managua, Nicaragua
| | | | - Mario Gamero
- Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Marco Luque
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | - Pamela Zacasa
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Maysam Homsi
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Miguela A Caniza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Ambuj Kumar
- Department of Internal Medicine, University of South Florida, Tampa, FL
| | - Sheena Mukkada
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
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Ockfen S, Egle L, Sauter K, Haber M, Becker SL, Wagenpfeil G, Graf N, Simon A. Meropenem Use in Pediatric Oncology - Audit on Indication, Appropriateness and Consumption Comparing Patient Derived and Pharmacy Dispensing Data. KLINISCHE PADIATRIE 2021; 233:278-285. [PMID: 34261135 DOI: 10.1055/a-1481-8905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Meropenem is an important second- or third-line antibiotic in pediatric cancer patients with febrile neutropenia (FN). Concise utilization data of meropenem in this setting is limited. It remains unclear how drug dispensing data from the hospital pharmacy correlate with data derived from patients' files. METHODS Retrospective audit of meropenem-consumption in a University-affiliated pediatric oncology center in days of therapy (DOT)/100 inpatient days. The individual indication for meropenem was critically reviewed. The real consumption (in g/100 inpatient days) was compared with the drug amounts dispensed by the hospital pharmacy (in gram and in defined daily doses (DDD)/100 inpatient days). All patients receiving at least one dose of meropenem from 1st of April 2016 until the 30th of June 2018 were included. RESULT Of 235 consecutive patients, 45 (19%) received meropenem, comprising 57 FN events. The probability of receiving at least one dose of meropenem was significantly higher in patients with ALL, AML, NHL and certain CNS tumors. Preceding the use of meropenem, only 5% of patients were known to be colonized with multidrug-resistant Gram-negative pathogens. Meropenem was administered as first-line treatment in 26% of all meropenem cycles, in 74% of all FN events with meropenem, Piperacillin-Tazobactam was used for initial treatment. In 5 of 57 FN events (8.8%), initial blood cultures yielded a Gram-negative pathogen. Concerning definite treatment, appropriate alternatives to meropenem with a smaller spectrum of activity would have been available in 4 cases, but a de-escalation was not performed. The median length of therapy in the meropenem group was 6 days, the corresponding median for days of therapy (DOT) was 12 days. This corresponds with combination therapy in 56% of all meropenem treatments, mostly with teicoplanin. On average, drug dispensing data from the hospital pharmacy were 1.53 times higher than real use (relying on patients' data) without a significant correlation. A higher Case-mix Index positively correlated with meropenem-consumption. CONCLUSION The use of meropenem should become a target of antibiotic stewardship programs in order to restrict its use to certain indications and preserve its outstanding role as second- or third-line antibiotic in this vulnerable population. Irrespective of the metrics used (g or DDD/100 inpatient days), pharmacy dispensing data do not accurately depict real patient-derived data concerning meropenem use in pediatric cancer patients.
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Affiliation(s)
- Svenja Ockfen
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Leonie Egle
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Katharina Sauter
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Manfred Haber
- Director Hospital Pharmacy, Saarland University Hospital, Homburg/Saar, Homburg, Germany
| | - Sören L Becker
- Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University, Campus Homburg, Institutes for Medical Biometry, Epidemiology and Medical Informatics (IMBEI), Homburg, Germany
| | - Norbert Graf
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Arne Simon
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
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Monsereenusorn C, Sricharoen T, Rujkijyanont P, Suwanpakdee D, Photia A, Lertvivatpong N, Traivaree C. Clinical Characteristics and Predictive Factors of Invasive Fungal Disease in Pediatric Oncology Patients with Febrile Neutropenia in a Country with Limited Resources. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2021; 12:335-345. [PMID: 34285630 PMCID: PMC8285294 DOI: 10.2147/phmt.s299965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/27/2021] [Indexed: 12/12/2022]
Abstract
Background The most common complication among pediatric oncology patients is febrile neutropenia (FN). Invasive fungal disease (IFD) is suspected when fever persists >4–7 days after empirical antibiotics. Its clinical characteristics and predictive factors associated with IFD among pediatric oncology patients with FN were thus explored. Methods Pediatric oncology patients with FN between January 1, 2012 and December 31, 2016 were enrolled in this study. Clinical characteristics, including laboratory investigations, treatment modalities, and final outcomes of IFD were retrospectively reviewed and analyzed. Results In all, 73 patients with 180 episodes of confirmed diagnosis of FN were studied. Median age at diagnosis was 6.2 years, with equal sex distribution. The most common diagnosis was acute lymphoblastic leukemia (n=91, 51%), followed by acute myeloid leukemia (n=47, 26%), Burkitt’s lymphoma (n=7, 4%) and neuroblastoma (n=7, 4%). Median absolute neutrophil count at FN diagnosis was 0 (0–806) cells/mm3. IFD was diagnosed for 25 (14%) episodes. Mortality rates for FN and IFD were 4% and 20%, respectively. Respiratory compromise, oxygen requirement, hypotension, prolonged hospitalization, duration of fever and neutropenia, bacteremia, bacteriuria, funguria, abnormal liver-function results, and prolonged broad-spectrum antibiotic administration were factors associated with IFD (P<0.05). Prolonged duration between initiation of fever and antifungal administration for nearly 10 days was an independent factor in prediction of IFD occurrence (P=0.014). Conclusion Respiratory compromise, oxygen requirement, hypotension, prolonged hospitalization, duration of fever and neutropenia, bacteremia, bacteriuria, funguria, abnormal liver-function results and prolonged broad-spectrum antibiotic administration were factors associated with IFD. Duration between initiation of fever and antifungal administration of nearly 10 days were considered a risk factors of IFD among patients with FN. IRB Reference Number IRBRTA 825/2560.
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Affiliation(s)
- Chalinee Monsereenusorn
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Piya Rujkijyanont
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Detchvijitr Suwanpakdee
- Division of Infectious Disease, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Apichat Photia
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Nawachai Lertvivatpong
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chanchai Traivaree
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
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Melgar MA, Homsi MR, Happ B, Su Y, Tang L, Gonzalez ML, Caniza MA. Survey of practices for the clinical management of febrile neutropenia in children in hematology-oncology units in Latin America. Support Care Cancer 2021; 29:7903-7911. [PMID: 34189607 PMCID: PMC8550596 DOI: 10.1007/s00520-021-06381-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/21/2021] [Indexed: 11/18/2022]
Abstract
The management of febrile neutropenia (FN) in pediatrics is evolving. Our objective was to describe current practices for the care of patients with FN in pediatric oncology centers in Latin America and identify areas for practice improvement. We used an online survey to enroll eligible healthcare providers who treat children with cancer in Latin America. The survey addressed respondents’ characteristics, the environment of care, and FN care practices, including risk assessment, criteria for hospitalization, initial management of FN, evaluation, antibiotic administration, and discharge. From 220 surveys sent, we received 109 responses and selected 108 from 19 countries for analysis. Most (94%) respondents were working in specialized oncology centers, oncology units within a pediatric or general care hospital. The cohort included oncologists (42%) and infectious diseases physicians (30%). Most (67%) respondents had available guidelines; they used a risk-stratification scoring system (73%) for severe infection; and their guidelines had locally adapted risk stratification (34%) or published risk stratification (51%). The respondents used diverse FN definitions and concepts, including fever definitions, temperature-obtaining methods, neutropenia values for assigning risk, empiric antimicrobials administration, and length of hospitalization. Overall, we detected common practices aligning with standard published recommendations, as well as care variability. These findings can guide further evaluations of care resources and practices to prioritize interventions, and professional networks can be used for FN discussions and consensus in Latin America.
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Affiliation(s)
- Mario A Melgar
- Department of Pediatrics, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Maysam R Homsi
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Brooke Happ
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Yin Su
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Miriam L Gonzalez
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Miguela A Caniza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA. .,Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA. .,Health Science Center, University of Tennessee, Memphis, TN, USA.
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Janssens KP, Valete COS, Silva ARAD, Ferman SE. Evaluation of risk stratification strategies in pediatric patients with febrile neutropenia. J Pediatr (Rio J) 2021; 97:302-308. [PMID: 32505617 PMCID: PMC9432306 DOI: 10.1016/j.jped.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/19/2020] [Accepted: 04/30/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To evaluate the performance of risk stratification protocols for febrile neutropenia specific to the pediatric population. METHODS Retrospective study of a cohort of pediatric patients undergoing cancer treatment with episodes of neutropenia due to chemotherapy and fever, treated at the emergency department of a tertiary cancer hospital from January 2015 to June 2017. Patients who were bone marrow transplant recipients and patients with neutropenia due to causes other than chemotherapy were excluded. Six protocols were applied to all patients: Rackoff, Alexander, Santolaya, Rondinelli, Ammann 2003, and Ammann 2010. The following outcomes were assessed: microbiological infection, death, ICU admission, and need for more than two antibiotics. The performance of each protocol was analyzed for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operator characteristic (ROC) curve. RESULTS This study evaluated 199 episodes of febrile neutropenia in 118 patients. Microbiological infection was identified in 70 samples from 45 distinct episodes (22.6%), 30 patients used more than two antibiotics during treatment (15%), eight required ICU admission (4%), and one patient died (0.8%). Three protocols achieved high sensitivity indices and NPV regarding the outcomes of death and ICU admission: Alexander, Rackoff, and Ammann 2010; however, Rackoff showed higher sensitivity (0.82) and NPV (0.9) in relation to the microbiological infection outcome. CONCLUSION The Rackoff risk rating showed the best performance in relation to microbiological infection, death, and ICU admission, making it eligible for prospective evaluation.
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Affiliation(s)
- Keegan Peter Janssens
- Instituto Nacional de Câncer (INCA), Departamento de Oncologia Pediátrica, Rio de Janeiro, RJ, Brazil.
| | | | | | - Sima Esther Ferman
- Instituto Nacional de Câncer (INCA), Departamento de Oncologia Pediátrica, Rio de Janeiro, RJ, Brazil
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Lamy B, Dutron S, Haouy S, Saumet L, Marchandin H, Sirvent N. Optimized blood culture strategy to document febrile neutropenia. Pediatr Res 2021; 89:1109-1116. [PMID: 32722662 DOI: 10.1038/s41390-020-1086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Poor and delayed microbiological documentation of episodes of febrile neutropenia (EFN) deserves improvement. We assessed the impact of a new blood culture (BC) sampling protocol to optimize the diagnosis of bloodstream infection during EFN, compared with standard of care protocol. METHODS This pre/post intervention included patients who presented an EFN in a pediatric hematology-oncology center. Data were compared between 1-year periods P1 (110 EFN, 53 patients) and P2 (124 EFN, 53 patients). Pre-intervention settings were 1-2 mL of blood cultured per BC set and several samplings over days (multisampling strategy) during period P1 vs. one unique early sampling of a large volume of blood (0.5-60 mL) depending on patient weight during period P2 (single-sampling weight-adapted strategy). Microbial detection and time-to-diagnosis were evaluated. RESULTS Seventeen EFNs were microbiologically documented in P1 (15.5%) and 26 in P2 (21%). The rate of positive BC sets increased during P2 (10.4% vs. 5.8%). All cases of bacteremia were documented by BC drawn during the first 4 days of fever, and during P2 by samples obtained on the first day of fever. CONCLUSIONS Bacteremia detection was improved. This proof-of-concept study shows benefits of combining the single-sampling strategy with large weight-adapted blood sampling strategy during EFN. IMPACT Combination of single-sampling and weight-adapted blood culture strategies showed benefits in the documentation of bloodstream infections during febrile neutropenia. Bacteremia detection was improved in this preliminary study and this warrants further evaluation in the overall pediatric population. We observed no adverse effects associated with the new strategy while overall blood sparing was improved and handling of intravascular devices was reduced. The good tolerance of the blood sampling suggests that the recommended 1% volume limitation in children could be reconsidered. A similar evaluation is justified in the overall pediatric population suspected for bloodstream infection.
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Affiliation(s)
- Brigitte Lamy
- INSERM U1065, Laboratoire de Bactériologie, CHU Nice, Faculté de Médecine, Université Côte d'Azur, Nice, France.
| | - Sarah Dutron
- Département d'oncologie et hématologie pédiatrique, CHU Montpellier, Montpellier, France
| | - Stéphanie Haouy
- Département d'oncologie et hématologie pédiatrique, CHU Montpellier, Montpellier, France
| | - Laure Saumet
- Département d'oncologie et hématologie pédiatrique, CHU Montpellier, Montpellier, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Université de Montpellier, CNRS, IRD, Montpellier, France.,Département de Microbiologie, CHU Nîmes, Nîmes, France
| | - Nicolas Sirvent
- Département d'oncologie et hématologie pédiatrique, CHU Montpellier, Montpellier, France
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Lehrnbecher T, Averbuch D, Castagnola E, Cesaro S, Ammann RA, Garcia-Vidal C, Kanerva J, Lanternier F, Mesini A, Mikulska M, Pana D, Ritz N, Slavin M, Styczynski J, Warris A, Groll AH. 8th European Conference on Infections in Leukaemia: 2020 guidelines for the use of antibiotics in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e270-e280. [PMID: 33811814 DOI: 10.1016/s1470-2045(20)30725-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/27/2022]
Abstract
Paediatric patients with cancer and those undergoing haematopoietic cell transplantation are at high risk of bacterial infections. The 8th European Conference on Infections in Leukaemia (ECIL-8) convened a Paediatric Group to review the literature and to formulate recommendations for the use of antibiotics according to the European Society of Clinical Microbiology and Infectious Diseases grading system. The evaluation of antibacterial prophylaxis included mortality, bloodstream infection, febrile neutropenia, emergence of resistance, and adverse effects as endpoints. Initial antibacterial therapy and antibiotic de-escalation or discontinuation focused on patients with a clinically stable condition and without previous infection or colonisation by resistant bacteria, and on patients with a clinically unstable condition or with previous infection or colonisation by resistant bacteria. The final considerations and recommendations of the ECIL-8 Paediatric Group on antibacterial prophylaxis, initial therapy, and de-escalation strategies are summarised in this Policy Review.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany.
| | - Dina Averbuch
- Department of Pediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roland A Ammann
- Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jukka Kanerva
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fanny Lanternier
- Infectious Diseases Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Alessio Mesini
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Dorothea Pana
- Department of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Nicole Ritz
- Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Monica Slavin
- Department of Infectious Diseases and National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
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40
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Morgan JE, Phillips B, Haeusler GM, Chisholm JC. Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children. Infect Drug Resist 2021; 14:1283-1293. [PMID: 33833534 PMCID: PMC8019605 DOI: 10.2147/idr.s238567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating de-escalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, 3168, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Julia C Chisholm
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, SM2 5PT, UK
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41
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Kebudi R. Acute invasive fungal sinusitis in immunocompromised children. Hematol Transfus Cell Ther 2021; 44:128-129. [PMID: 33773957 PMCID: PMC8885361 DOI: 10.1016/j.htct.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/27/2021] [Indexed: 10/31/2022] Open
Affiliation(s)
- Rejin Kebudi
- Istanbul University, Oncology Institute, Istanbul, Turkey.
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42
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Kuehnel NA, McCreary E, Henderson SL, Vanderloo JP, Hoover-Regan ML, Sharp B, Ross J. Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department. Pediatr Qual Saf 2021; 6:e390. [PMID: 38571520 PMCID: PMC10990408 DOI: 10.1097/pq9.0000000000000390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018. Methods Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results. Results The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017. Conclusions Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.
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Affiliation(s)
- Nicholas A Kuehnel
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Erin McCreary
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sheryl L Henderson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Joshua P Vanderloo
- Department of Pharmacy, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Margo L Hoover-Regan
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Brian Sharp
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Joshua Ross
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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43
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Abebe W, Bacha T, Shane AL, Berkowitz T. Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia. Afr J Emerg Med 2021; 11:20-25. [PMID: 33312850 PMCID: PMC7721625 DOI: 10.1016/j.afjem.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022] Open
Abstract
Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.
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44
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Bay SB, Kebudi R. Respiratory viral panel testing in children with cancer and respiratory tract infections. Pediatr Blood Cancer 2021; 68:e28773. [PMID: 33058455 DOI: 10.1002/pbc.28773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Sema Buyukkapu Bay
- Department of Pediatric Hematology-Oncology, Oncology Institute, Istanbul University, Istanbul, Turkey
| | - Rejin Kebudi
- Department of Pediatric Hematology-Oncology, Oncology Institute, Istanbul University, Istanbul, Turkey.,Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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45
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Herberger S, Oberkircher N, Wenzel GI, Hecker D, Wagenpfeil G, Furtwängler R, Becker SL, Papan C, Graf N, Simon A. [Prospektives Audit des Gentamicin Drug Monitorings in einem Kinderkrebszentrum]. KLINISCHE PADIATRIE 2021; 233:123-126. [PMID: 33601432 DOI: 10.1055/a-1352-5053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many pediatric cancer centers still use Gentamicin as first line combination treatment in patients with fever and neutropenia. Since 2011, our center has implemented a dosing regimen with 250 mg/m2 BSA (max. 10 mg/kg, max. 400 mg) as a single daily infusion according to the German guideline. PATIENTS AND METHODS In this prospective audit (February 2011 to December 2019), 105 Gentamicin treatment cycles were analyzed in 66 pediatric cancer patients, focusing on adherence to the dosing regimen and the drug monitoring results. RESULTS Adherence to the dosing regimen was high (89%). In 64% of all cycles, the Cmax (drawn 1 h after the 2nd dose) reached the target of 10-20 µg/ml. Cmax significantly correlated with dosing in mg/m2 BSA (p=0,007), but not with dosing in mg/kg (p=0,366). Age below 6 years did not influence these results. The Gentamicin Ctrough (drawn 8-10 h after the second dose) was < 2 µg/ml in 93% of all cycles without any dose correlation. None of the patients experienced Gentamicin-associated nephrotoxicity. DISCUSSION AND CONCLUSION This prospective audit of single daily infusion Gentamicin in pediatric cancer patients without impaired renal function elicits the feasibility and safety of the dosing regimen in mg/m2 BSA according to the German guideline. Since indications for first-line gentamicin are limited, a multicenter prospective study would be advantageous to confirm these observations.
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Affiliation(s)
- Sarah Herberger
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Nadine Oberkircher
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gentiana I Wenzel
- Otorhinolaryngology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Dietmar Hecker
- Otorhinolaryngology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Rhoikos Furtwängler
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Sören L Becker
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Cihan Papan
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Norbert Graf
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Arne Simon
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
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46
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Olson J, Mehra S, Hersh AL, Thorell EA, Stoddard GJ, Maese L, Barnette PE, Lemons RS, Pavia AT, Knackstedt ED. Oral Step-Down Therapy With Levofloxacin for Febrile Neutropenia in Children With Cancer. J Pediatric Infect Dis Soc 2021; 10:27-33. [PMID: 32092134 DOI: 10.1093/jpids/piaa015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although febrile neutropenia (FN) is a frequent complication in children with cancer receiving chemotherapy, there remains significant variability in selection of route (intravenous [IV] vs oral) and length of therapy. We implemented a guideline with a goal to change practice from using IV antibiotics after hospital discharge to the use of step-down oral therapy with levofloxacin for most children with FN until absolute neutrophil count > 500. The objectives of this study were to determine the impact of this guideline on home IV antibiotic use, and to evaluate the safety of implementation of this guideline. METHODS We performed a quasi-experimental, pre-post study of discharge FN treatment at a stand-alone children's hospital in patients without bacteremia discharged between January 2013 and October 2018. In January 2015, a multidisciplinary team created a guideline to switch most children with FN to oral levofloxacin, which was formally implemented as of September 2017. Discharges during the postintervention period (after September 2017) were compared to discharges in the preintervention period (between January 2013 and December 2014). RESULTS In adjusted multivariable regression analyses, the postimplementation period was associated with a decrease in home IV antibiotics (adjusted risk ratio [aRR], 0.07 [95% confidence interval {CI}, .03-.13]) and fewer IV antibiotic initiations within 24 hours of a new healthcare encounter up to 7 days after discharge (aRR, 0.39 [95% CI, .17-.93]) compared to the preintervention time period. CONCLUSIONS Step-down oral levofloxacin for children with FN who are afebrile with an ANC ≤ 500 at discharge is feasible and resulted in similar clinical outcomes compared to home IV antibiotics.
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Affiliation(s)
- Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sonia Mehra
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emily A Thorell
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Luke Maese
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Phillip E Barnette
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard S Lemons
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Elizabeth D Knackstedt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark JE. Improving management of fever in neutropenic children with cancer across multiple sites. Eur J Cancer Care (Engl) 2021; 30:e13413. [PMID: 33511731 DOI: 10.1111/ecc.13413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.
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Affiliation(s)
- Katrina Anderson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre and Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Qld, Australia
| | - Rachel Edwards
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jessica Nicholson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, South Brisbane, Qld, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Australia
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48
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Zajac-Spychala O, Kampmeier S, Lehrnbecher T, Groll AH. Infectious Complications in Paediatric Haematopoetic Cell Transplantation for Acute Lymphoblastic Leukemia: Current Status. Front Pediatr 2021; 9:782530. [PMID: 35223707 PMCID: PMC8866305 DOI: 10.3389/fped.2021.782530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) in paediatric patients with acute lymphoblastic leukaemia (ALL) is associated with a variety of infectious complications which result in significant morbidity and mortality. These patients are profoundly immunocompromised, and immune reconstitution after HSCT generally occurs in astrictly defined order. During the early phase after HSCT until engraftment, patients are at risk of infections due to presence of neutropenia and mucosal damage, with Gramme-positive and Gramme-negative bacteria and fungi being the predominant pathogens. After neutrophil recovery, the profound impairment of cell-mediated immunity and use of glucocorticosteroids for control of graft-vs.-host disease (GvHD) increases the risk of invasive mould infection and infection or reactivation of various viruses, such as cytomegalovirus, varicella zoster virus, Epstein-Barr virus and human adenovirus. In the late phase, characterised by impaired cellular and humoral immunity, particularly in conjunction with chronic GvHD, invasive infections with encapsulated bacterial infections are observed in addition to fungal and viral infections. HSCT also causes a loss of pretransplant naturally acquired and vaccine-acquired immunity; therefore, complete reimmunization is necessary to maintain long-term health in these patients. During the last two decades, major advances have been made in our understanding of and in the control of infectious complications associated with HSCT. In this article, we review current recommendations for the diagnosis, prophylaxis and treatment of infectious complications following HSCT for ALL in childhood.
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Affiliation(s)
- Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
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49
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Shinn K, Wetzel M, DeGroote NP, Keller F, Briones M, Felker J, Castellino S, Miller TP. Impact of respiratory viral panel testing on length of stay in pediatric cancer patients admitted with fever and neutropenia. Pediatr Blood Cancer 2020; 67:e28570. [PMID: 32881268 PMCID: PMC7721999 DOI: 10.1002/pbc.28570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Polymerase chain reaction (PCR) respiratory viral panel (RVP) testing is often used in evaluation of pediatric cancer patients with febrile neutropenia (FN), but correlation with adverse outcomes has not been well characterized. PROCEDURE A retrospective cohort of all children ages 0-21 years with cancer admitted to Children's Healthcare of Atlanta for FN from January 2013 to June 2016 was identified. Patient demographic and clinical variables such as age, RVP results, length of stay (LOS), and deaths were abstracted. Relationship between RVP testing and positivity and LOS, highest temperature (Tmax), hypotension and intensive care unit (ICU) admission were compared using Wilcoxon rank sums, chi-square, or Fisher's exact tests adjusting for age, sex, bacteremia, and diagnosis. RESULTS The 404 patients identified had 787 total FN admissions. RVPs were sent in 38% of admissions and were positive in 59%. Patients with RVPs sent were younger (median 5.5 vs 8.0 years, P < .0001) with higher Tmax (39.2° vs 39.1°, P = .016). The most common virus identified was rhinovirus/Enterovirus (61%). There were no significant differences in highest temperature or lowest blood pressure based on RVP positivity. Patients admitted to the ICU were more likely to have RVPs sent (odds ratio [OR] = 3.19, P < .002); however, neither having RVP testing nor RVP positivity were significantly associated with increased LOS or death. Coinfection with bacteremia and a respiratory virus was identified in 9.1% of patients. CONCLUSIONS These data raise the question of the utility of sending potentially costly RVP testing as RVP positivity during febrile neutropenia does not impact LOS, degree of hypotension, or ICU admission.
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Affiliation(s)
| | - Martha Wetzel
- Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Frank Keller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - James Felker
- Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Sharon Castellino
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Tamara P. Miller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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Ok ZO, Kupeli S, Sezgin G, Bayram I. Comparison of Different Doses of Granulocyte Colony-stimulating Factor in the Treatment of High-risk Febrile Neutropenia in Children With Cancer. J Pediatr Hematol Oncol 2020; 42:e738-e744. [PMID: 32925403 DOI: 10.1097/mph.0000000000001940] [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] [Indexed: 02/07/2023]
Abstract
Febrile neutropenia (FEN) is a significant side effect after chemotherapy, and it is known that using granulocyte colony-stimulating factor (G-CSF) has positive effects on treatment results. In this study, the effects of different G-CSF doses (5 to 10 mcg/kg/day) on treatment results in patients with high-risk FEN were evaluated. A total of 124 high-risk FEN episodes of 62 patients were enrolled in the study between June 2017 and October 2018. The episodes were divided into 2 groups according to G-CSF treatment doses, they received from 5 to 10 mcg/kg/day. The clinical characteristics of the patients, the treatments they received, laboratory findings, microbiologic results, and cost analysis were recorded. No statistically significant difference was found between 2 groups in terms of the mean duration of recovery from neutropenia, duration of fever, total length of hospital stay, duration of FEN episode, duration of G-CSF use, costs, bacteremia frequency, and other treatments. In patients with solid tumors, the cost of filgrastim was significantly higher in the high-dose G-CSF group. Using different doses of G-CSF in high-risk FEN episodes did not show any different effects on clinical and treatment results. The dose of 5 mcg/kg/day would be more appropriate in FEN treatment.
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Affiliation(s)
- Zahide Orhan Ok
- Department of Pediatric Oncology/Pediatric Bone Marrow Transplantation Unit, Cukurova, University, Faculty of Medicine, Adana, Turkey
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