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Aspects of infections in children with cancer
1Department of Infectious Diseases, University of Genova, Italy.
Insights
Pediatric cancer patients experience fewer infections than adults, but central venous catheter infections are common. Gram-positive bacteria cause most catheter infections, and treatment without device removal is often successful.
Area of Science:
- Oncology
- Infectious Diseases
- Pediatrics
Background:
- Pediatric cancer patients exhibit distinct infection profiles compared to adults, with lower mortality rates.
- Central venous catheters are crucial for cancer treatment, particularly in pediatric oncology.
- Catheter-related infections (CRIs) are a significant concern in pediatric cancer patients undergoing chemotherapy and radiotherapy.
Purpose of the Study:
- To investigate the characteristics and management of catheter-related infections in pediatric cancer patients.
- To evaluate the efficacy of different empirical antibiotic regimens for CRIs.
- To determine the optimal antibiotic strategy for gram-positive infections in this population.
Main Methods:
- Prospective study of 157 Broviac catheters in pediatric cancer patients.
- Microbiological documentation of infections and pathogen identification.
- Pilot study comparing ceftazidime + amikacin vs. ceftazidime + vancomycin for empirical treatment.
Main Results:
- 27% of documented infections in pediatric cancer patients were catheter-related.
- Gram-positive cocci were the predominant pathogens (78%) causing CRIs.
- CRIs occurred frequently in non-neutropenic patients and could be treated without catheter removal.
- Vancomycin-containing regimens showed a trend towards advantage but were not statistically significant; some staphylococcal infections required additional antibiotics.
Conclusions:
- Catheter-related infections are common in pediatric cancer patients, predominantly caused by gram-positive organisms.
- Successful treatment of CRIs without device removal is feasible.
- The increasing prevalence of gram-positive infections warrants careful consideration of empirical antibiotic coverage, potentially including vancomycin, but further multicenter trials are needed to define optimal strategies, especially in the context of methicillin-resistant staphylococci.
Abstract:
There are some differences between pediatric and adult cancer patients in terms of the problem of infection but it is doubtful whether such discrepancies justify different therapeutic approaches. For example, according to the results of EORTC trial IV, children seem to show lower overall (3% vs 19%) and infectious (2% vs 8%) mortality than adults, probably due to differences in underlying diseases and to a basic better physical integrity. Central intravenous catheters appear to be indispensable in the modern management of neoplastic diseases, especially in pediatric oncology. A prospective study performed in our institution on 157 Broviac catheters, has shown: 1. Of all microbiologically documented infections, occurring in children undergoing cancer chemotherapy and radiotherapy, 27% are related to the catheter 2. Gram-positive cocci are the leading pathogens (78%) of such infections 3. Catheter-related infections often occur in non-neutropenic patients 4. Such infections can be successfully treated without removing the intravenous device. The experience of the EORTC Cooperative Group and of other centers throughout the world shows that gram-positive cocci are increasingly being isolated as the cause of infections in cancer patients. This phenomenon is probably multifactorial in origin and appears to be more evident in pediatrics. For example, in our institution, during the last 5 years gram-positive organisms have caused 69% of all bacteremias. Moreover, these organisms, while responding poorly to the presently used empirical antibiotic regimens, seem not to be as aggressive as gram-negative organisms and cause lower mortality. There is therefore controversy over whether or not to include anti-gram-positive coverage in early empirical regimens. In our institution, a pilot study comparing ceftazidime + amikacin (C + A) and ceftazidime + vancomycin (C + V) seems to show an overall advantage for C + V. This advantage, however, is not statistically significant. One finding to be pointed out is that five of ten staphylococcal infections failed to respond to C + V and that in these cases a third antibiotic had to be added. Therefore, it is likely that, at least in institutions in which methicillin-resistant staphylococci are prevalent, a triple antibiotic empirical regimen will provide the best coverage, but this can result in overtreatment. However, only prospective, randomized and multicenter trials will be able to answer such questions definitely.