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Koenig C, Ammann RA, Schneider C, Wyss J, Roessler J, Brack E. Continuous timely monitoring of core temperature with two wearable devices in pediatric patients undergoing chemotherapy for cancer - a comparison study. Support Care Cancer 2024; 32:188. [PMID: 38400942 PMCID: PMC10894150 DOI: 10.1007/s00520-024-08366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 02/11/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Pediatric patients with cancer often develop chemotherapy-induced fever in neutropenia (FN), requiring emergency broad-spectrum antibiotics. Continuous temperature monitoring can lead to earlier FN detection and therapy with improved outcomes. We aimed to compare the feasibility of continuous core temperature monitoring with timely data availability between two wearable devices (WDs) in pediatric oncology patients undergoing chemotherapy. METHODS In this prospective observational two-center study, 20 patients (median age: 8 years) undergoing chemotherapy simultaneously wore two WDs (CORE®, Everion®) for 14 days. The predefined goal was core temperature recorded in sufficient quality and available within ≤ 30 min during ≥ 18/24 h for ≥ 7/14 days in more than 15 patients. RESULTS More patients reached the goal with CORE® (n = 13) versus Everion® (n = 3) (difference, 50% p < 0.001). After correcting for the transmission bottleneck caused by two WDs transmitting via one gateway, these numbers increased (n = 15 versus n = 14; difference, 5%; p = 0.69). CORE® measurements corresponded better to ear temperatures (n = 528; mean bias, - 0.07 °C; mean absolute difference, 0.35 °C) than Everion® measurements (n = 532; - 1.06 °C; 1.10 °C). Acceptance rates for the WDs were 95% for CORE® and 89% for Everion®. CONCLUSION The CORE® fulfilled the predefined feasibility criterion (15 of 20 patients) after correction for transmission bottleneck, and the Everion® nearly fulfilled it. Continuous core temperature recording of good quality and with timely data availability was feasible from preschool to adolescent patients undergoing chemotherapy for cancer. These results encourage the design of randomized controlled trials on continuously monitored core temperature in pediatric patients. TRIAL REGISTRATION CLINICALTRIALS gov (NCT04914702) on June 7, 2021.
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Affiliation(s)
- Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Roland A Ammann
- , StatConsult Ammann, Burgdorf, Switzerland
- Faculty of Medicine, University of Bern, CH-3010, Bern, Switzerland
| | - Christine Schneider
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Johanna Wyss
- Department of Pediatric Oncology and Hematology, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Eva Brack
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
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De Castro GC, Slatnick LR, Shannon M, Zhao Z, Jackson K, Smith CM, Whitehurst D, Elliott C, Clark CC, Scott HF, Friedman DL, Demedis J, Esbenshade AJ. Impact of Time-to-Antibiotic Delivery in Pediatric Patients With Cancer Presenting With Febrile Neutropenia. JCO Oncol Pract 2024; 20:228-238. [PMID: 38127868 PMCID: PMC10911541 DOI: 10.1200/op.23.00583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Febrile neutropenia (FN) in pediatric patients with cancer can cause severe infections, and prompt antibiotics are warranted. Extrapolated from other populations, a time-to-antibiotic (TTA) metric of <60 minutes after medical center presentation was established, with compliance data factoring into pediatric oncology program national rankings. METHODS All FN episodes occurring at Vanderbilt Children's Hospital (2007-February 2022) and a sample of episodes from Colorado Children's Hospital (2012-2019) were abstracted, capturing TTA and clinical outcomes including major complications (intensive care unit [ICU] admission, vasopressors, intubation, or infection-related mortality). Odds ratios (ORs) were adjusted for age, treatment center, absolute neutrophil count, hypotension presence, stem-cell transplant status, and central line type. RESULTS A total of 2,349 episodes were identified from Vanderbilt (1,920) and Colorado (429). Only 0.6% (n = 14) episodes required immediate ICU management, with a median TTA of 28 minutes (IQR, 20-37). For the remaining patients, the median TTA was 56 minutes (IQR, 37-90), and 54.3% received antibiotics in <60 minutes. There were no significant associations between TTA (<60 or ≥60 minutes) and major complications (adjusted OR, 0.99 [95% CI, 0.62 to 1.59]; P = .98), and a TTA ≥60 minutes was not associated with any type of complication. Similarly, TTA, when evaluated as a continuous variable, was not associated with a major (OR, 0.99 [95% CI, 0.94 to 1.04]; P = .69) nor any other complication in adjusted analysis. CONCLUSION There is no clear evidence that a reduced TTA improves clinical outcomes in pediatric oncology FN and thus it should not be used as a primary quality measure.
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Affiliation(s)
| | - Leonora R. Slatnick
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | | | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Kasey Jackson
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Christine M. Smith
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Claire Elliott
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Chelsea C. Clark
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Halden F. Scott
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Debra L. Friedman
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Jenna Demedis
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Adam J. Esbenshade
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Simon A, Lehrnbecher T, Baltaci Y, Dohna-Schwake C, Groll A, Laws HJ, Potratz J, Hufnagel M, Bochennek K. [Time to Antibiotics (TTA) - Reassessment from the German Working Group for Fever and Neutropenia in Children and Adolescents (DGPI/GPOH)]. Klin Padiatr 2023; 235:331-341. [PMID: 37751768 DOI: 10.1055/a-2135-4210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND The current German guidance from 2016 recommends a Time to Antibiotics (TTA) of<60 min in children and adolescents with febrile neutropenia (FN). METHODS Critical analysis of available studies and recent meta-analyses, and discussion of the practical consequences in the FN working group of the German Societies for Paediatric Oncology and Haematology and Paediatric Infectious Diseases. RESULTS The available evidence does not support a clinically significant outcome benefit of a TTA<60 min in all paediatric patients with FN. Studies suggesting such a benefit are biased (mainly triage bias), use different TTA definitions and display further methodical limitations. In any case, a TTA<60 min remains an essential component of the 1st hour-bundle in paediatric cancer patients with septic shock or sepsis with organ dysfunction. CONCLUSION Provided that all paediatric FN patients receive a structured medical history and physical examination (including vital signs) by experienced and trained medical personnel in a timely fashion, and provided that a sepsis triage and management bundle is established and implemented, a TTA lower than 3 hours is sufficient and reasonable in stable paediatric cancer patients with FN.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Homburg, Homburg, Germany
| | - Thomas Lehrnbecher
- Klinik für Kinder- und Jugendheilkunde, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt, Germany
| | - Yeliz Baltaci
- Pädiatrische Onkologie und Hämatologie, TeleKasper Projekt, Universitätskinderklinik Homburg, Homburg, Germany
| | | | - Andreas Groll
- Päd. Hämatologie und Onkologie, Univ.-Klinikum Münster, Klinik für Kinder- und Jugendmedizin, Münster, Germany
| | - Hans-Jürgen Laws
- Klinik für Kinder-Onkologie, - Hämatologie und - Klinische Immunologie, Universerstitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Jenny Potratz
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Münster, Muenster, Germany
| | - Markus Hufnagel
- Klinik für Kinderheilkunde und Jugendmedizin, Universitätskinderklinik Freiburg, Freiburg, Germany
| | - Konrad Bochennek
- Pädiatrische Hämatologie und Onkologie, Universitätsklinik Frankfurt, Frankfurt, Germany
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Wösten-van Asperen RM, la Roi-Teeuw HM, van Amstel RBE, Bos LDJ, Tissing WJE, Jordan I, Dohna-Schwake C, Bottari G, Pappachan J, Crazzolara R, Comoretto RI, Mizia-Malarz A, Moscatelli A, Sánchez-Martín M, Willems J, Rogerson CM, Bennett TD, Luo Y, Atreya MR, Faustino ES, Geva A, Weiss SL, Schlapbach LJ, Sanchez-Pinto LN. Distinct clinical phenotypes in paediatric cancer patients with sepsis are associated with different outcomes-an international multicentre retrospective study. EClinicalMedicine 2023; 65:102252. [PMID: 37842550 PMCID: PMC10570699 DOI: 10.1016/j.eclinm.2023.102252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Background Identifying phenotypes in sepsis patients may enable precision medicine approaches. However, the generalisability of these phenotypes to specific patient populations is unclear. Given that paediatric cancer patients with sepsis have different host response and pathogen profiles and higher mortality rates when compared to non-cancer patients, we determined whether unique, reproducible, and clinically-relevant sepsis phenotypes exist in this specific patient population. Methods We studied patients with underlying malignancies admitted with sepsis to one of 25 paediatric intensive care units (PICUs) participating in two large, multi-centre, observational cohorts from the European SCOTER study (n = 383 patients; study period between January 1, 2018 and January 1, 2020) and the U.S. Novel Data-Driven Sepsis Phenotypes in Children study (n = 1898 patients; study period between January 1, 2012 and January 1, 2018). We independently used latent class analysis (LCA) in both cohorts to identify phenotypes using demographic, clinical, and laboratory data from the first 24 h of PICU admission. We then tested the association of the phenotypes with clinical outcomes in both cohorts. Findings LCA identified two distinct phenotypes that were comparable across both cohorts. Phenotype 1 was characterised by lower serum bicarbonate and albumin, markedly increased lactate and hepatic, renal, and coagulation abnormalities when compared to phenotype 2. Patients with phenotype 1 had a higher 90-day mortality (European cohort 29.2% versus 13.4%, U.S. cohort 27.3% versus 11.4%, p < 0.001) and received more vasopressor and renal replacement therapy than patients with phenotype 2. After adjusting for severity of organ dysfunction, haematological cancer, prior stem cell transplantation and age, phenotype 1 was associated with an adjusted OR of death at 90-day of 1.9 (1.04-3.34) in the European cohort and 1.6 (1.2-2.2) in the U.S. cohort. Interpretation We identified two clinically-relevant sepsis phenotypes in paediatric cancer patients that are reproducible across two international, multicentre cohorts with prognostic implications. These results may guide further research regarding therapeutic approaches for these specific phenotypes. Funding Part of this study is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Roelie M. Wösten-van Asperen
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Hannah M. la Roi-Teeuw
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Rombout BE. van Amstel
- Intensive Care, Amsterdam UMC—location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lieuwe DJ. Bos
- Intensive Care, Amsterdam UMC—location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim JE. Tissing
- Princess Máxima Centre for Pediatric Oncology, Utrecht, the Netherlands
- Department of Paediatric Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Iolanda Jordan
- Department of Paediatric Intensive Care and Institut de Recerca, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Christian Dohna-Schwake
- Department of Paediatrics I, Paediatric Intensive Care, Children’s Hospital Essen, Germany
- West German Centre for Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Gabriella Bottari
- Paediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCSS, Rome, Italy
| | - John Pappachan
- Department of Paediatric Intensive Care, Southampton Children’s Hospital, UK
| | - Roman Crazzolara
- Department of Paediatrics, Paediatric Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Rosanna I. Comoretto
- Department of Paediatric Intensive Care, Department of Woman's and Child's Health, Padua University Hospital, Padua, Italy
| | - Agniezka Mizia-Malarz
- Department of Paediatric Oncology, Haematology and Chemotherapy Unit, Medical University of Silesia, Katowice, Poland
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - María Sánchez-Martín
- Department of Paediatric Intensive Care, Hospital Universitario La Paz, Madrid, Spain
| | - Jef Willems
- Department of Paediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Colin M. Rogerson
- Department of Paediatrics, Division of Critical Care, Indianapolis University School of Medicine, Indianapolis, IN, USA
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Paediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mihir R. Atreya
- Department of Paediatrics (Critical Care), University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Centre, Cincinnati, OH, USA
| | | | - Alon Geva
- Department of Anaesthesiology, Critical Care, and Pain Medicine and Computational Health Informatics Program, Boston Children's Hospital, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Scott L. Weiss
- Division of Critical Care, Department of Paediatrics, Nemours Children’s Health, Delaware, USA
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Centre, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - L Nelson Sanchez-Pinto
- Department of Paediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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Willis DN, McGlynn MC, Reich PJ, Hayashi RJ. Mortality in pediatric oncology and stem cell transplant patients with bloodstream infections. Front Oncol 2023; 12:1063253. [PMID: 36713545 PMCID: PMC9874914 DOI: 10.3389/fonc.2022.1063253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Bloodstream infections (BSI) continue to represent a significant source of morbidity for pediatric oncology patients, however less is known regarding this population's risk of death. We sought to evaluate the risk of BSI and death at a large pediatric cancer center. Methods We retrospectively collected inpatient data from pediatric oncology and hematopoietic stem cell transplant (HSCT) patients over a 9-year period. We performed univariate and multivariable modeling to assess risk of BSI and mortality examining the following variables: demographics, underlying malignancy, history of HSCT, central line type, and febrile neutropenia (FN). Results During the study period, 6763 admissions from 952 patients met inclusion criteria. BSI occurred in 367 admissions (5.4%) from 231 unique individuals. Risk factors for BSI include younger age, diagnoses of hemophagocytic lymphohistiocytosis or acute myeloid leukemia, ethnicity, and history of HSCT. Mortality for those with BSI was 6.5%, compared to 0.7% without (OR 7.2, CI 4.1 - 12.7, p<0.0001). In patients with BSI, admissions with FN were associated with reduced mortality compared to admissions without FN (OR 0.21, CI 0.05 - 0.94, p=0.04). In both univariate and multivariable analysis, no other risk factor was significantly associated with mortality in patients with BSI. Conclusion BSI is a significant source of mortality in pediatric oncology and HSCT patients. While demographic variables contribute to the risk of BSI, they did not influence mortality. These findings highlight the importance of BSI prevention to reduce the risk of death in pediatric oncology patients. Future studies should focus on comprehensive BSI prevention.
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Affiliation(s)
- Daniel N. Willis
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States,*Correspondence: Daniel N. Willis,
| | - Mary Claire McGlynn
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
| | - Patrick J. Reich
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
| | - Robert J. Hayashi
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
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Villars J, Gardner CA, Zhan T, Binder AF. Delay in Time to Antibiotics for De Novo Inpatient Neutropenic Fever May Not Impact Overall Survival for Patients With a Cancer Diagnosis. Am J Med Qual 2023; 38:9-16. [PMID: 36579961 DOI: 10.1097/jmq.0000000000000093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Neutropenic fever (NF) is an oncologic emergency for which expert consensus recommends that anti-pseudomonas antibiotics be administered within 60 minutes of detection. This study investigated whether delays in time to antibiotics (TTA) impacted overall survival (OS) for patients with hematological malignancies who developed inpatient NF via a retrospective cohort study of 187 de novo NF cases categorized by TTA (<1, 1-2, 2-3, 3-4 and >4 hours). OS at 180 days post-NF episode was compared using Kaplan-Meier estimates and multivariable Cox proportional hazards model. TTA did not significantly affect OS (P = 0.420). Patients with Charleston Comorbidity Indexes ≥3, a measure of overall health, had higher hazard (hazard ratio [HR] = 2.728, 95% confidence interval, 1.265-5.882, P = 0.010). TTA delays in the hospital may not be long enough to cause significant patient harm. Larger studies may be needed to detect small, but significant mortality differences.
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Affiliation(s)
- Jordan Villars
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | | | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Adam F Binder
- Department of Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplant, Sidney Kimmel Cancer Center, Thomas Jefferson University Hospital, Philadelphia, PA
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Koenig C, Kuehni CE, Bodmer N, Agyeman PKA, Ansari M, Roessler J, von der Weid NX, Ammann RA. Time to antibiotics is unrelated to outcome in pediatric patients with fever in neutropenia presenting without severe disease during chemotherapy for cancer. Sci Rep 2022; 12:14028. [PMID: 35982121 PMCID: PMC9388602 DOI: 10.1038/s41598-022-18168-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) remains an unavoidable, potentially lethal complication of chemotherapy. Timely administration of empirical broad-spectrum intravenous antibiotics has become standard of care. But the impact of time to antibiotics (TTA), the lag period between recognition of fever or arrival at the hospital to start of antibiotics, remains unclear. Here we aimed to analyze the association between TTA and safety relevant events (SRE) in data from a prospective multicenter study. We analyzed the association between time from recognition of fever to start of antibiotics (TTA) and SRE (death, admission to intensive care unit, severe sepsis and bacteremia) with three-level mixed logistic regression. We adjusted for possible triage bias using a propensity score and stratified the analysis by severity of disease at presentation with FN. We analyzed 266 FN episodes, including 53 (20%) with SRE, reported in 140 of 269 patients recruited from April 2016 to August 2018. TTA (median, 120 min; interquartile range, 49-180 min) was not associated with SRE, with a trend for less SREs in episodes with longer TTA. Analyses applying the propensity score suggested a relevant triage bias. Only in patients with severe disease at presentation there was a trend for an association of longer TTA with more SRE. In conclusion, TTA was unrelated to poor clinical outcome in pediatric patients with FN presenting without severe disease. We saw strong evidence for triage bias which could only be partially adjusted.
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Affiliation(s)
- Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Bodmer
- Pediatric Oncology, Kinderspital Zürich, University of Zürich, Zurich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Ansari
- Pediatric Hematology/Oncology, Department of Women, Child and Adolescent, University Hospital of Geneva, Geneva, Switzerland.,Department of Pediatrics, Gynecology, and Obstetrics, Cansearch Research Platform of Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Nicolas X von der Weid
- Division of Pediatric Hematology and Oncology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.,Kinderaerzte KurWerk, Burgdorf, Switzerland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gulleen EA, Lubwama M, Komakech A, Krantz EM, Liu C, Phipps W. Knowledge and perceptions of antimicrobial resistance and antimicrobial stewardship among staff at a national cancer referral center in Uganda. Antimicrob Steward Healthc Epidemiol 2022; 2:e54. [PMID: 36483337 PMCID: PMC9726558 DOI: 10.1017/ash.2022.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES As access to cancer care has improved throughout sub-Saharan Africa, treatment-associated infections have increased. Assessing healthcare worker knowledge of antimicrobial stewardship and identifying the barriers to infection management will inform the development of contextually appropriate antimicrobial stewardship programs, improving cancer outcomes in sub-Saharan Africa. DESIGN Cross-sectional survey. SETTING The Uganda Cancer Institute (UCI), a national cancer referral center in Kampala, Uganda. PARTICIPANTS We surveyed 61 UCI staff: 29 nurses, 7 pharmacists, and 25 physicians. METHODS The survey contained 25 questions and 1 ranking exercise. We examined differences in responses by staff role. RESULTS All 60 respondents who answered the question had heard the term "antimicrobial resistance." Only 44 (73%) had heard the term "antimicrobial stewardship." Nurses were less likely than pharmacists or physicians to be familiar with either term. Also, 41 respondents (68%) felt that loss of antibiotic susceptibility is a major issue at UCI. Regarding barriers to diagnosing infections, 54 (93%) of 58 thought that it was difficult to obtain blood cultures and 48 (86%) of 56 thought that it was difficult to regularly measure temperatures. CONCLUSIONS Although most recognized the term "antimicrobial resistance," fewer were familiar with the term "antimicrobial stewardship." Inappropriate antibiotic use was recognized as a contributor to antimicrobial resistance, but hand hygiene was underrecognized as a contributing factor. We identified numerous barriers to diagnosing infections, including the ability to obtain blood cultures and consistently monitor temperatures. Educating staff regarding antimicrobial selection, allocating resources for blood cultures, and implementing strategies to enhance fever detection will improve infection management.
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Affiliation(s)
- Elizabeth A. Gulleen
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States
- Allergy and Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, United States
- Seattle Cancer Care Alliance, Seattle, Washington, United States
| | - Margaret Lubwama
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Alfred Komakech
- Department of Pharmacy, Uganda Cancer Institute, Kampala, Uganda
| | - Elizabeth M. Krantz
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States
| | - Catherine Liu
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States
- Allergy and Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, United States
- Seattle Cancer Care Alliance, Seattle, Washington, United States
| | - Warren Phipps
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States
- Allergy and Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, United States
- Seattle Cancer Care Alliance, Seattle, Washington, United States
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10
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Oh BLZ, Fan L, Lee SHR, Foo KM, Chiew KH, Seeto ZZL, Chen ZW, Neoh CCC, Liew GSM, Eng JJ, Lam JCM, Quah TC, Tan AM, Chan YH, Yeoh AEJ. Life-threatening infections during treatment for acute lymphoblastic leukemia on the Malaysia-Singapore 2003 and 2010 clinical trials: A risk prediction model. Asia Pac J Clin Oncol 2022; 18:e456-e468. [PMID: 35134276 DOI: 10.1111/ajco.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
AIM Life-threatening infections significantly impact the care of children undergoing therapy for acute lymphoblastic leukemia (ALL) who are at risk of severe sepsis due to both host and treatment factors. Our aim was to develop a life-threatening infection risk prediction model that would allow remote rapid triage of patients to reduce time to first dose of antibiotics and sepsis-related mortality. METHODS A retrospective analysis of 2068 fever episodes during ALL therapy was used for model building and subsequent internal validation. RESULTS Three hundred and seventy-seven patients were treated for ALL in two institutions with comparable critical and supportive care resources. A total of 55 patients accounted for 71 admissions to the critical care unit for sepsis that led to eight septic deaths during a 16-year study period. A retrospective analysis of risk factors for sepsis enabled us to build a model focused on 13 variables that discriminated admissions requiring critical care well: area under the receiver operating characteristic curve of .82; 95% CI .76-.87, p<.001, and Brier score of .033. Significant univariate predictors included neutropenia, presence of symptoms of abdominal pain, diarrhea, fever during induction or steroid-based phases, and the lack of any localizing source of infection at time of presentation. CONCLUSION We have developed a risk prediction model that can reliably identify ALL patients undergoing treatment who are at a higher risk of life-threatening sepsis. Clinical applicability can potentially be extended to low-middle income settings, and its utility should be further studied in real-world settings.
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Affiliation(s)
- Bernice L Z Oh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Lijia Fan
- Division of Critical Care, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shawn H R Lee
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Koon Mian Foo
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Kean Hui Chiew
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Zelia Z L Seeto
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Zhi Wei Chen
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Cheryl C C Neoh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore
| | - Germaine S M Liew
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Jing Jia Eng
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Joyce C M Lam
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Thuan Chong Quah
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Ah Moy Tan
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Allen E J Yeoh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
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11
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Gerber N, Vella A, Racine-Brzostek S, Platt SL. Rapid Absolute Neutrophil Count Testing Guides Targeted Antimicrobial Therapy in Febrile Pediatric Oncology Patients. Pediatr Emerg Care 2022; 38:e743-e745. [PMID: 35100772 DOI: 10.1097/pec.0000000000002354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES It is well established that early antibiotic administration leads to improved outcomes in febrile neutropenic patients. To achieve this, many institutions administer empiric antibiotics to all febrile oncology patients in the emergency setting, before knowing their neutropenic status. This study evaluates the role of rapid absolute neutrophil count (ANC) testing in the targeted antimicrobial management of nonneutropenic febrile oncology patients. METHODS We conducted a retrospective review of patients 19 years or younger presenting to the pediatric emergency service with an oncologic process and fever or history of fever. We examined the administration of antibiotics and outcomes in nonneutropenic patients. RESULTS We included 101 patient encounters, representing 62 distinct patients. The rapid ANC test influenced antibiotic management in 94% (95/101) of patient encounters and resulted in no antibiotics or targeted antibiotic therapy in 88% (60/68) of nonneutropenic patients. Use of the rapid ANC test to guide treatment would have spared antibiotic administration in 68% (46/68) of well-appearing nonneutropenic patients with no alternate indication. No well-appearing, nonneutropenic patient had a positive blood culture, and only 1 required hospital admission on a repeat visit. CONCLUSIONS The rapid ANC is a useful tool to balance the goal of early antibiotic administration in febrile neutropenic oncology patients while promoting antibiotic stewardship in this vulnerable population.
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Affiliation(s)
| | - Adam Vella
- From the Department of Emergency Medicine
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12
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Lipe DN, Bourenane SS, Wattana MK, Gaeta S, Chaftari P, Cruz Carreras MT, Manzano J, Reyes-gibby C. A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19. Am J Emerg Med 2022. [PMID: 35152119 PMCID: PMC8817422 DOI: 10.1016/j.ajem.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
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13
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Seltzer JA, Frankfurt O, Kyriacou DN. Association of an emergency department febrile neutropenia intervention protocol with time to initial antibiotic treatment. Acad Emerg Med 2022; 29:73-82. [PMID: 34245642 DOI: 10.1111/acem.14335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Earlier initial antibiotic treatment for febrile neutropenia is associated with improved clinical outcomes. This study was conducted to evaluate the association of an emergency department (ED) intervention protocol with time to initial antibiotic treatment for febrile neutropenia patients. METHODS We conducted a cohort study of adult ED febrile neutropenia patients before and after implementation of an intervention protocol. Analyses included comparison of means and medians, Kaplan-Meier estimates, multivariable regression analyses, interrupted time-series analyses, and causal mediation analyses. The intervention protocol included specific triage and process-of-care actions to reduce the primary outcome of time to initial antibiotic treatment. RESULTS There were 69 patients in the 12-month preintervention period and 52 patients in the 8-month postintervention period. The mean (±SD) times to initial antibiotics were 197.6 (±85.4) min for the preintervention group and 97.7 (±51.0) min for the postintervention group (difference of 99.9 min with 95% confidence interval [CI] = 73.5 to 126.4, p < 0.001). The patients' probability for receiving initial antibiotics within 90 min was severalfold greater (adjusted risk ratio = 10.31, 95% CI = 4.99 to 21.30, p < 0.001) for the postintervention group versus preintervention group. ED length of stay, hospital length of stay, 30-day readmissions, and 30-day all-cause mortality were not different between the study groups. The association of the intervention protocol with time to initial antibiotics appeared to be mediated through times to treatment room placement, report of absolute neutrophil count, and initial antibiotic order. CONCLUSIONS The intervention protocol was associated with a significant reduction in time to initial antibiotics for ED patients with febrile neutropenia. This association appears to be facilitated through specific intermediate process-of-care variables. A larger multicenter study is needed to assess the potential effects of an ED febrile neutropenia protocol on patient-centered clinical outcomes and resource utilization.
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Affiliation(s)
- Justin A. Seltzer
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Olga Frankfurt
- Division of Hematology and Oncology Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Demetrios N. Kyriacou
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
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14
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Sukauichai S, Lamaikul S. A Retrospective Study of Febrile Neutropenia From a Cancer Hospital: Pathogenic Organisms, Time to Antibiotic Administration, and Prognostic Factors. Infect Dis Clin Pract 2022; 30. [DOI: 10.1097/ipc.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Nanayakkara AK, Boucher HW, Fowler VG, Jezek A, Outterson K, Greenberg DE. Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward. CA Cancer J Clin 2021; 71:488-504. [PMID: 34546590 DOI: 10.3322/caac.21697] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/23/2021] [Accepted: 08/12/2021] [Indexed: 12/13/2022] Open
Abstract
Infection is the second leading cause of death in patients with cancer. Loss of efficacy in antibiotics due to antibiotic resistance in bacteria is an urgent threat against the continuing success of cancer therapy. In this review, the authors focus on recent updates on the impact of antibiotic resistance in the cancer setting, particularly on the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.). This review highlights the health and financial impact of antibiotic resistance in patients with cancer. Furthermore, the authors recommend measures to control the emergence of antibiotic resistance, highlighting the risk factors associated with cancer care. A lack of data in the etiology of infections, specifically in oncology patients in United States, is identified as a concern, and the authors advocate for a centralized and specialized surveillance system for patients with cancer to predict and prevent the emergence of antibiotic resistance. Finding better ways to predict, prevent, and treat antibiotic-resistant infections will have a major positive impact on the care of those with cancer.
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Affiliation(s)
- Amila K Nanayakkara
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern, Dallas, Texas
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Amanda Jezek
- Infectious Diseases Society of America, Arlington, Virginia
| | - Kevin Outterson
- CARB-X, Boston, Massachusetts
- Boston University School of Law, Boston, Massachusetts
| | - David E Greenberg
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern, Dallas, Texas
- Department of Microbiology, University of Texas Southwestern, Dallas, Texas
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16
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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: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Rapoport BL, Cooksley T, Johnson DB, Anderson R, Shannon VR. Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC). Expert Rev Clin Pharmacol 2021; 14:295-313. [PMID: 33517803 DOI: 10.1080/17512433.2021.1884067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with hematological and advanced solid malignancies have acquired immune dysfunction, often exacerbated by treatment, posing a significant risk for the development of infections. This review evaluates the utility of current clinical and treatment guidelines, in the setting of management of infections in cancer patients. AREAS COVERED These include causes of infection in cancer patients, management of patients with high-risk and low-risk febrile neutropenia, management of low-risk patients in an outpatient setting, the role of granulocyte colony-stimulating factor (G-CSF) in the prevention and treatment of neutropenia-related infections, management of lung infections in various clinical settings, and emerging challenges surrounding the risk of infection in cancer patients treated with novel treatments. The literature search was performed by accessing PubMed and other databases, focusing on published clinical trials of relevant anti-cancer agents and diseases, primarily covering the recent past, but also including several key studies published during the last decade and, somewhat earlier in a few cases. EXPERT REVIEW Notwithstanding the promise of gene therapy/gene editing in hematological malignancies and some types of solid cancers, innovations introduced in clinical practice include more discerning clinical management such as the generalized use of biosimilar formulations of G-CSF and the implementation of novel, innovative immunotherapies.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Medical Oncology Centre of Rosebank, Saxonwold, Johannesburg, South Africa.,The Multinational Association for Supportive Care in Cancer (MASCC), Chair of the Neutropenia, Infection and Myelosuppression Study Group
| | - Tim Cooksley
- Manchester University Foundation Trust, Manchester, United Kingdom. The Christie, University of Manchester, Manchester, UK.,The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group
| | - Douglas B Johnson
- Douglas B. Johnson, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
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19
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Koenig C, Ammann RA, Kuehni CE, Roessler J, Brack E. Continuous recording of vital signs with a wearable device in pediatric patients undergoing chemotherapy for cancer-an operational feasibility study. Support Care Cancer 2021; 29:5283-5292. [PMID: 33655413 PMCID: PMC7925259 DOI: 10.1007/s00520-021-06099-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/19/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric patients with cancer are at high risk for severe infections. Infections can trigger changes of vital signs long before clinical symptoms arise. Continuous recording may detect such changes earlier than discrete measurements. We aimed to assess the feasibility of continuous recording of vital signs by a wearable device (WD) in pediatric patients undergoing chemotherapy for cancer. METHODS In this prospective, observational single-center study, pediatric patients under chemotherapy wore the Everion® WD for 14 days. The predefined patient-specific goal was heart rate recorded in good quality during ≥18/24 h per day, on ≥7 consecutive days. The predefined criterion to claim feasibility was ≥15/20 patients fulfilling this patient-specific goal. RESULTS Twenty patients were included (median age, 6 years; range, 2-16). Six patients aged 3-16 years fulfilled the patient-specific goal. Quality of heart rate recording was good during 3992 of 6576 (61%) hours studied and poor during 300 (5%) hours, and no data was recorded during 2284 (35%) hours. Eighteen of 20 participants indicated that this WD is acceptable to measure vital signs in children under chemotherapy. CONCLUSION The predefined feasibility criterion was not fulfilled. This was mainly due to important compliance problems and independent of the WD itself. However, continuous recording of vital signs was possible across a very wide age range in pediatric patients undergoing chemotherapy for cancer. We recommend to study feasibility in the Everion® again, plus in further WDs, applying measures to enhance compliance. TRIAL REGISTRATION ClinicalTrials.gov (NCT04134429) on October 22, 2019.
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Affiliation(s)
- Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva Brack
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Scheler M, Lehrnbecher T, Groll AH, Volland R, Laws HJ, Ammann RA, Agyeman P, Attarbaschi A, Lux M, Simon A. Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland. Infection 2020; 48:607-18. [PMID: 32524514 DOI: 10.1007/s15010-020-01462-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/02/2020] [Indexed: 12/19/2022]
Abstract
Purpose Investigation of the current practice of diagnostics and treatment in pediatric cancer patients with febrile neutropenia. Methods On behalf of the German Society for Pediatric Oncology and Hematology and the German Society for Pediatric Infectious Diseases, an Internet-based survey was conducted in 2016 concerning the management of febrile neutropenia in pediatric oncology centers (POC). This survey accompanied the release of the corresponding German guideline to document current practice before its implementation in clinical practice. Results In total, 51 POCs participated (response rate 73%; 43 from Germany, and 4 each from Austria and Switzerland). Identified targets for antimicrobial stewardship concerned blood culture diagnostics, documentation of the time to antibiotics, the use of empirical combination therapy, drug monitoring of aminoglycosides, the time to escalation in patients with persisting fever, minimal duration of IV treatment, sequential oral treatment in patients with persisting neutropenia, indication for and choice of empirical antifungal treatment, and the local availability of a pediatric infectious diseases consultation service. Conclusion This survey provides useful information for local antibiotic stewardship teams to improve the current practice referring to the corresponding national and international guidelines. Electronic supplementary material The online version of this article (10.1007/s15010-020-01462-z) contains supplementary material, which is available to authorized users.
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Phillips B. Recent advances in the prevention and management of infections in children undergoing treatment for cancer. F1000Res 2019; 8. [PMID: 31754423 PMCID: PMC6852340 DOI: 10.12688/f1000research.19337.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 11/20/2022] Open
Abstract
A major consequence of the intensive multi-modal chemotherapy commonly used to treat malignancies in childhood is life-threatening infection, frequently during periods of profound neutropenia. Recent advances have been made in all areas of management, from trying to prevent infection to getting patients off antimicrobials and home again in the shortest, safest way. Potential avenues of further research are outlined for readers to be aware of in the next few years.
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Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, YO10 5DD, UK.,Leeds Children's Hospital, Leeds General Infirmary, Leeds, Yorkshire, LS1 9EX, UK
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Koenig C, Schneider C, Morgan JE, Ammann RA, Sung L, Phillips B. Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review. Support Care Cancer 2019; 28:2369-2380. [PMID: 31486984 PMCID: PMC7083808 DOI: 10.1007/s00520-019-05056-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Purpose Multiple interventions have been developed aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia (FN) following chemotherapy for cancer. We evaluated their effect to reduce TTA and their impact on important clinical outcomes in a systematic review. Methods The search covered seven databases. Biases and quality of studies were assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Interventions could be implemented in any setting and performed by any person included in the FN management. Absolute change of TTA was the primary outcome. Registration: PROSPERO (CRD42018092948). Results Six thousand two hundred ninety-six titles and abstracts were screened, 177 studies were retrieved and 30 studies were included. Risk of bias was moderate to serious in 28 studies and low in two studies. All but one study reported a reduction of TTA after the intervention. Various types of interventions were implemented; they most commonly aimed at professionals. Most of the studies made more than one single intervention. Conclusion This review may help centers to identify their specific sources of delay and barriers to change and to define what intervention may be the best to apply. This review supports the assertion that TTA can be considered a measure of quality of care, emphasizes the importance of education and training, and describes the very different interventions which have effectively reduced TTA. Electronic supplementary material The online version of this article (10.1007/s00520-019-05056-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland. .,Centre for Reviews and Dissemination, University of York, York, UK.
| | - Christine Schneider
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Lillian Sung
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
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