The influence of different fever definitions on the rate of fever in neutropenia diagnosed in children with cancer

Palm cooling temperatures on thermal, physiological, perceptual, and ergogenic indices from rowing workouts in a thermoneutral environment

Gel pack temperatures were compared for responses to thermal, physiological, perceptual, and ergogenic indices from healthy women (n = 12) and men (n = 8). They did three rowing workouts to identify an ideal temperature. In a randomised sequence, and as subjects wore gloves equipped with mesh pouches during workouts, gel packs at one of the three average temperatures (10.6, 12.6, or 14.9°C) were inserted into the pouches. Data were collected before, during and after multi-stage workouts. Thermal, physiological, and perceptual data were each compared with three-factor (condition, gender, time) mixed effect model ANCOVAs, with repeated measures for condition and time, and gender as a between subjects' factor. Distance rowed was assessed with two-factor (condition, gender) mixed effect model ANCOVAs, with repeated measures for condition, and gender as a between subjects' factor. Within-subject contrasts was the post-hoc, and α = 0.05 denoted significance. Despite small differences for distance rowed, many dependent variables had significant inter-condition effects, whereby 10.6°C gel packs had the best thermal and physiological responses. The 10.6°C temperature 1): likely removed the most body heat, perhaps through cold-induced vasodilation and, 2): may be optimal, as it evoked the best thermal and physiological responses.

Survey of practices for the clinical management of febrile neutropenia in children in hematology-oncology units in Latin America

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.

Evaluation of a Wearable Non-Invasive Thermometer for Monitoring Ear Canal Temperature during Physically Demanding (Outdoor) Work

Aimed at preventing heat strain, health problems, and absenteeism among workers with physically demanding occupations, a continuous, accurate, non-invasive measuring system may help such workers monitor their body (core) temperature. The aim of this study is to evaluate the accuracy and explore the usability of the wearable non-invasive Cosinuss° °Temp thermometer. Ear canal temperature was monitored in 49 workers in real-life working conditions. After individual correction, the results of the laboratory and field study revealed high correlations compared to ear canal infrared thermometry for hospital use. After performance of the real-life working tasks, this correlation was found to be moderate. It was also observed that the ambient environmental outdoor conditions and personal protective clothing influenced the accuracy and resulted in unrealistic ear canal temperature outliers. It was found that the Cosinuss° °Temp thermometer did not result in significant interference during work. Therefore, it was concluded that, without a correction factor, the Cosinuss° °Temp thermometer is inaccurate. Nevertheless, with a correction factor, the reliability of this wearable ear canal thermometer was confirmed at rest, but not in outdoor working conditions or while wearing a helmet or hearing protection equipment.

Temperatures, diagnostics and treatment in pediatric cancer patients with fever in neutropenia, NCT01683370

In pediatric oncology, there is no evidence-based definition of the temperature limit defining fever (TLDF), which itself is essential for the definition of fever in chemotherapy-induced severe neutropenia (FN). Lowering the TLDF can increase the number of FN episodes diagnosed. This prospective, single center observational study collected data on all temperature measurements, complete blood counts (CBCs), and measures of diagnostics and therapy performed at and after FN diagnosis in pediatric oncology patients using a high standard TLDF (39 °C ear temperature). In 45 FN episodes in 20 patients, 3391 temperature measurements and 318 CBCs, plus information on antibiotics, anti-fungal therapy, antipyretics, blood cultures taken and on discharge were collected. These data can mainly be used to study the influence of virtually lowering the TLDF on diagnostic measures, treatment and length of hospitalization in pediatric FN, which in turn are directly related to costs of FN therapy, and quality of life. This approach can be expanded to include as well different definitions of neutropenia.

Measurement(s)	body temperature trait • Blood Cell Count • Diagnostics, Cancer • therapy
Technology Type(s)	Thermometer Device • complete blood cell count • Observational study
Factor Type(s)	day and time • outcome
Sample Characteristic - Organism	Homo sapiens
Sample Characteristic - Environment	hospital

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.12118473

A Phase 2, International, Multicenter, Open-label Clinical Trial of Subcutaneous Tbo-Filgrastim in Pediatric Patients With Solid Tumors Undergoing Myelosuppressive Chemotherapy

This phase 2, multicenter, open-label trial investigated the safety and tolerability of tbo-filgrastim in pediatric patients receiving myelosuppressive chemotherapy. In total, 50 patients 1 month to below 16 years of age with solid tumors without bone marrow involvement were stratified into 3 age groups (2 infants, 30 children, 18 adolescents) and prophylactically administered tbo-filgrastim 5 µg/kg body weight once daily subcutaneously. The administration started after the last chemotherapy treatment in week 1 of the first cycle and continued until the expected neutrophil nadir had passed, and the neutrophil count had recovered to 2.0×10/L. The primary endpoint was safety and tolerability of tbo-filgrastim; secondary endpoints included efficacy. The mean (SD) number of doses administered was 9.2 (2.83) in children and 7.3 (1.88) in adolescents. Serious treatment-emergent adverse events were reported in 24% of patients; the most common were febrile neutropenia (FN) (12%), anemia (8%), and thrombocytopenia (8%). Nine patients (18%) experienced mild treatment-related treatment-emergent adverse events; the most common were musculoskeletal and connective tissue disorders (8%). No deaths or withdrawals occurred. The incidence of severe neutropenia (SN) was 52% and the mean (SD) duration of SN was 1.8 (2.21) days; FN incidence was 26%. A daily dose of tbo-filgrastim 5 μg/kg body weight administered to pediatric patients demonstrated a safety profile consistent with the safety profile in adult patients. The incidence of FN was on the lower end of the range reported in the literature and the SN results provide supportive data on the efficacy of tbo-filgrastim in pediatric patients.

Temperatures and blood counts in pediatric patients treated with chemotherapy for cancer, NCT01683370

Fever in neutropenia (FN) is the most frequent potentially lethal complication of chemotherapy in patients with cancer. The temperature limit defining fever (TLDF) for FN is based on scarce evidence. This prospective, single center observational study recruited non-selected pediatric patients diagnosed with cancer between ≥1 and ≤17 years in 2012 and 2013. Of 40 patients potentially eligible, 39 participated. Data of 8896 temperature measurements and 1873 complete blood counts (CBCs) were recorded over 289 months (24.1 years) of chemotherapy exposure time. During this time 43 FN episodes were diagnosed. In 32 episodes, FN diagnosis was based on reaching the local (i.e. Bern, Switzerland) standard TLDF of 39.0 °C; another 11 episodes had been captured by clinical judgement (i.e. temperature < 39.0 °C). These data can be used to simulate the effects of various TLDFs on the rate of FN diagnosis. We assume merging these data with other data sets is feasible.

Design Type(s)	observation design • cohort study design • disease detection/diagnosis objective
Measurement Type(s)	body temperature • complete blood cell count
Technology Type(s)	thermometry • blood analyzer
Factor Type(s)
Sample Characteristic(s)	Homo sapiens • whole body • Switzerland

Machine-accessible metadata file describing the reported data (ISA-Tab format)

Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012

Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop complications, integrated into clinical decision rules, would allow for risk-stratified treatment of FN. This retrospective, single center cohort study in pediatric patients diagnosed with cancer before 17 years, covered two decades, 1993 to 2012. In total, 703 FN episodes in 291 patients with chemotherapy (maximum per patient, 9) were reported here. Twenty-nine characteristics of FN were collected: 6 were patient- and cancer-related, 8 were characteristics of history, 8 of clinical examination, and 7 laboratory results in peripheral blood, all known at FN diagnosis. In total 28 FN outcomes were assessed: 8 described treatment of FN, 6 described microbiologically defined infections (MDI), 4 clinically defined infections, 4 were additional clinical composite outcomes, and 6 outcomes were related to discharge. These data can mainly be used to study FN characteristics and their association with outcomes over time and between centers, and for derivation and external validation of clinical decision rules.

Pediatric patients at risk for fever in chemotherapy-induced neutropenia in Bern, Switzerland, 1993-2012

Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop FN during chemotherapy would allow for targeted prophylaxis. This retrospective, single centre cohort study in pediatric patients diagnosed with cancer before 17 years covered two decades, 1993 to 2012. The 583 (73%) of 800 patients diagnosed with cancer who had received chemotherapy were studied here. Data on 2113 observation periods was collected, defined by stable combinations of 11 predefined characteristics potentially associated with FN. They covered 692 years of cumulative chemotherapy exposure time, during which 712 FN episodes were diagnosed, 154 (22%) of them with bacteremia. The risk to develop FN and FN with bacteremia remained stable over time. These data can mainly be used to study FN risks over time and between centers, and to derive or externally validate FN risk prediction rules.

The influence of different fever definitions on diagnostics and treatment after diagnosis of fever in chemotherapy-induced neutropenia in children with cancer

Background

There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy.

Methods

In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon.

Results

In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days.

Conclusion

Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.

Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: Results of a French nationwide survey

BACKGROUND

In 2012, new international guidelines for children with chemotherapy-induced febrile neutropenia (FN) were issued, recommending reduced-intensity management strategy based on stratification of infectious risks. Some studies have highlighted practice disparities in different countries and within the same country. Our aim was to assess the current management strategies for the treatment of chemotherapy-induced FN in children in France.

PROCEDURE

This survey of all French pediatric oncology-hematology reference centers (n = 30) in late 2012 and early 2013 sent a standardized questionnaire to each center inquiring about their definition of an FN episode, its initial empiric treatment and ongoing management, use of management stratified by risk, and any criteria used for the risk assessment. Each center's management protocol was also analyzed.

RESULTS

All French reference centers participated in this survey, completing 88% of the questionnaire items. Definitions of both fever and neutropenia varied between centers. Ten centers used a risk-stratification strategy for initial management. In all, 42 probabilistic first-line antibiotic treatments were identified. After 48 hr of apyrexia, 17 units applied different forms of step-down therapy.

CONCLUSIONS

Most French centers already offered some form of reduced-intensity or step-down therapy, although they differed substantially in their management of FN episodes. Risk stratification with validated tools is essential to facilitate the implementation of the international recommendations, which would ultimately help to standardize practices in France.

Systematic review of reduced therapy regimens for children with low risk febrile neutropenia

PURPOSE

Reduced intensity therapy for children with low-risk febrile neutropenia may provide benefits to both patients and the health service. We have explored the safety of these regimens and the effect of timing of discharge.

METHODS

Multiple electronic databases, conference abstracts and reference lists were searched. Randomised controlled trials (RCT) and prospective observational cohorts examining the location of therapy and/or the route of administration of antibiotics in people younger than 18 years who developed low-risk febrile neutropenia following treatment for cancer were included. Meta-analysis using a random effects model was conducted. I (2) assessed statistical heterogeneity not due to chance.

REGISTRATION

PROSPERO (CRD42014005817).

RESULTS

Thirty-seven studies involving 3205 episodes of febrile neutropenia were included; 13 RCTs and 24 prospective observational cohorts. Four safety events (two deaths, two intensive care admissions) occurred. In the RCTs, the odds ratio for treatment failure (persistence, worsening or recurrence of fever/infecting organisms, antibiotic modification, new infections, re-admission, admission to critical care or death) with outpatient treatment was 0.98 (95% confidence interval (95%CI) 0.44-2.19, I (2) = 0 %) and with oral treatment was 1.05 (95%CI 0.74-1.48, I (2) = 0 %). The estimated risk of failure using outpatient therapy from all prospective data pooled was 11.2 % (95%CI 9.7-12.8 %, I (2) = 77.2 %) and using oral antibiotics was 10.5 % (95%CI 8.9-12.3 %, I (2) = 78.3 %). The risk of failure was higher when reduced intensity therapies were used immediately after assessment, with lower rates when these were introduced after 48 hours.

CONCLUSIONS

Reduced intensity therapy for specified groups is safe with low rates of treatment failure. Services should consider how these can be acceptably implemented.

Management of fever and neutropenia in paediatric cancer patients: room for improvement?

PURPOSE OF REVIEW

Fever and neutropenia is the most common complication in the treatment of childhood cancer. This review will summarize recent publications that focus on improving the management of this condition as well as those that seek to optimize translational research efforts.

RECENT FINDINGS

A number of clinical decision rules are available to assist in the identification of low-risk fever and neutropenia however few have undergone external validation and formal impact analysis. Emerging evidence suggests acute fever and neutropenia management strategies should include time to antibiotic recommendations, and quality improvement initiatives have focused on eliminating barriers to early antibiotic administration. Despite reported increases in antimicrobial resistance, few studies have focused on the prediction, prevention, and optimal treatment of these infections and the effect on risk stratification remains unknown. A consensus guideline for paediatric fever and neutropenia research is now available and may help reduce some of the heterogeneity between studies that have previously limited the translation of evidence into clinical practice.

SUMMARY

Risk stratification is recommended for children with cancer and fever and neutropenia. Further research is required to quantify the overall impact of this approach and to refine exactly which children will benefit from early antibiotic administration as well as modifications to empiric regimens to cover antibiotic-resistant organisms.