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Predicting Infectious ComplicatioNs in Children with Cancer: an external validation study
Gabrielle M Haeusler1,2,3,4, Karin A Thursky2,5,6,7, Francoise Mechinaud8
1The Paediatric Integrated Cancer Service, 50 Flemington Road, Parkville, Victoria 3052, Australia.
Insights
The Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) clinical decision rule showed lower accuracy for predicting infection in children with cancer and fever/neutropenia upon initial presentation. However, its performance improved for bloodstream infections and after overnight observation, suggesting potential for safe, cost-saving low-risk pathways.
Area of Science:
- Pediatric Oncology
- Infectious Diseases
- Clinical Decision Rules
Background:
- Fever and neutropenia (FN) in children with cancer poses a significant risk of serious infection.
- Accurate prediction of microbiologically documented infection (MDI) is crucial for appropriate management.
- The Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) clinical decision rule (CDR) was developed to aid in this prediction.
Purpose of the Study:
- To validate the PICNICC CDR for predicting MDI in Australian children with cancer experiencing FN.
- To assess the cost-effectiveness of current FN management strategies.
Main Methods:
- Retrospective collection of data from 650 FN episodes, including demographics, outcomes, and costs.
- Assessment of the PICNICC CDR's discrimination, calibration, sensitivity, and specificity.
- Comparison of the CDR's performance in the validation cohort versus its derivation dataset.
Main Results:
- The PICNICC CDR performed poorly upon initial presentation without recalibration (AUC-ROC 0.638).
- Recalibration and application at day 2, considering known MDI proportions, improved sensitivity to 87.7%.
- Predictive ability for bacteraemia was similar to the derivation study, especially after recalibration (AUC-ROC 0.71).
- Length of stay significantly contributes to FN treatment costs (AUD 2183/day).
Conclusions:
- The PICNICC CDR requires local recalibration for optimal performance in predicting MDI in this cohort.
- The rule shows promise for identifying low-risk patients after a short observation period, potentially reducing healthcare costs.
- Implementing a low-risk pathway using the PICNICC CDR after inpatient observation may be safe and cost-effective.
Background:
The aim of this study was to validate the 'Predicting Infectious ComplicatioNs in Children with Cancer' (PICNICC) clinical decision rule (CDR) that predicts microbiologically documented infection (MDI) in children with cancer and fever and neutropenia (FN). We also investigated costs associated with current FN management strategies in Australia.
Methods:
Demographic, episode, outcome and cost data were retrospectively collected on 650 episodes of FN. We assessed the discrimination, calibration, sensitivity and specificity of the PICNICC CDR in our cohort compared with the derivation data set.
Results:
Using the original variable coefficients, the CDR performed poorly. After recalibration the PICNICC CDR had an area under the receiver operating characteristic (AUC-ROC) curve of 0.638 (95% CI 0.590-0.685) and calibration slope of 0.24. The sensitivity, specificity, positive predictive value and negative predictive value of the PICNICC CDR at presentation was 78.4%, 39.8%, 28.6% and 85.7%, respectively. For bacteraemia, the sensitivity improved to 85.2% and AUC-ROC to 0.71. Application at day 2, taking into consideration the proportion of MDI known (43%), further improved the sensitivity to 87.7%. Length of stay is the main contributor to cost of FN treatment, with an average cost per day of AUD 2183 in the low-risk group.
Conclusions:
For prediction of any MDI, the PICNICC rule did not perform as well at presentation in our cohort as compared with the derivation study. However, for bacteraemia, the predictive ability was similar to that of the derivation study, highlighting the importance of recalibration using local data. Performance also improved after an overnight period of observation. Implementation of a low-risk pathway, using the PICNICC CDR after a short period of inpatient observation, is likely to be safe and has the potential to reduce health-care expenditure.
