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Suspected infection in children with cancer
1Oncology Unit, Children's Hospital at Westmead, Hawksbury Road, Westmead, NSW 2145, Australia. peters@nch.edu.au
Insights
Infections are a common complication for children with cancer undergoing intensive therapy. This study tracked sepsis episodes, noting increased fungal infections and the growing use of lipid formulations for amphotericin B to reduce toxicity.
Area of Science:
- Pediatric Oncology
- Infectious Diseases
- Pharmacology
Background:
- Infections pose a significant risk to children undergoing intensive cancer therapy.
- The Children's Hospital at Westmead has a database for suspected sepsis admissions.
Purpose of the Study:
- To analyze trends in infection management and outcomes in pediatric cancer patients.
- To evaluate the use and impact of empirical antibiotics and antifungal agents, including lipid formulations of amphotericin B.
Main Methods:
- Retrospective analysis of 2331 episodes of suspected sepsis from July 1994 to June 1999.
- Documented use of broad-spectrum antibiotics, empirical amphotericin B, and granulocyte colony-stimulating factor.
- Recorded incidence of bacteremia, invasive fungal disease, and specific pathogens.
Main Results:
- Increased use of granulocyte colony-stimulating factor (40% to 60%) and a decrease in neutrophil counts upon antibiotic cessation.
- Rise in non-albicans Candida species and Scedosporium sp. infections.
- Reduced use of vancomycin-containing regimens and increased use of lipid formulations of amphotericin B for high-risk patients.
Conclusions:
- Infection remains a critical cause of mortality in pediatric cancer patients.
- Lipid formulations of amphotericin B are increasingly utilized to manage fungal infections with reduced nephrotoxicity.
- Trends indicate evolving strategies in empirical antimicrobial and antifungal therapy for pediatric oncology patients.
Abstract:
A common complication of the intensive therapy that children with cancer receive is infection. The Oncology Unit of The Children's Hospital at Westmead maintains a comprehensive database of all admissions for suspected sepsis. From July 1994 to June 1999 broad-spectrum antibiotics were commenced in 2331 episodes. With early and aggressive use of empirical amphotericin B, 545 courses were given. Bacteraemia was documented in 701 episodes and invasive fungal disease in 73. Trends seen during the study included: (i) the proportion of febrile neutropenic patients receiving granulocyte colony stimulating factor increased from 40% to 60%; (ii) the mean neutrophil count at cessation of antibiotics fell from 0.97 to 0.63 x 10(9) cells/L for patients not receiving growth factors; (iii) the proportion of non-albicans Candida species infections increased. In addition, an outbreak of infection caused by Scedosporium sp. was documented; (iv) first-line empirical antibiotic combinations containing vancomycin fell from 20% to 7%; and (v) the ability to maintain or escalate anti-fungal therapy with reduced nephrotoxicity through use of lipid formulations of amphotericin was increasingly apparent in high-risk patients. During the study, infection was the primary cause of death in 11 non-bone marrow transplant (BMT) patients (five fungal, four viral, one bacterial infection and one sepsis syndrome) and five BMT patients (two bacterial and three viral). A prospective randomized study of toxicity due to amphotericin B given in either lipid emulsion or dextrose showed no significant difference, but both groups showed a lower incidence of amphotericin B intolerance in comparison with the adult series. The inability to reduce toxicity of amphotericin B by simple mixing with lipid emulsion has led to increasing use of commercially available lipid formulations of amphotericin B.