Predicting bacteremia in children with fever and chemotherapy-induced neutropenia

BACKGROUND: Fever and neutropenia are common clinical problems in pediatric oncology and frequently necessitate emergency hospitalization and immediate empiric broad spectrum antimicrobial therapy. Estimating the risk of bacteremia in fever and neutropenia is a challenge. The purpose of this study was to develop an algorithm predicting the risk of bacteremia and Gram-negative bacteremia in children and adolescents with fever and neutropenia, based on information accessible at presentation. METHODS: We collected information available within 2 h of presentation of children with fever and neutropenia and, on outcome, from all pediatric cancer patients presenting with fever and neutropenia from 1993 through 2001 in a retrospective single center cohort study. After univariate analyses a multivariate decision tree was constructed, and its performance was evaluated by cross-validation. RESULTS: Bacteremia was detected in 87 (24%) and Gram-negative bacteremia in 30 (8%) of 364 episodes of fever and neutropenia. At the predetermined sensitivity level, > or =95%, decision tree models reached cross-validated specificities of 37 and 43%, with negative predictive values of 96 and 99%, for bacteremia and Gram-negative bacteremia, respectively. Absence of a clinically or radiologically evident source of infection and previous episodes of fever and neutropenia were defined as two newly described factors associated with bacteremia. CONCLUSIONS: Based on this retrospective analysis, it appears that bacteremia can be predicted with clinically useful specificity at a high level of sensitivity, using clinical information available at presentation in pediatric cancer patients with fever and neutropenia.     

The accuracy of mother's touch to detect fever in children: a systematic review

Universally, mothers often use touching to detect fever in their children. We perform a systematic review of published diagnostic studies evaluating the ability of mothers to detect fever in their children by touching. We found 10 studies satisfying our inclusion criteria. The meta-analysis revealed a summary sensitivity of 89.2% and summary specificity of 50%-maternal touch is perhaps more useful to exclude fever rather than to 'rule in' fever. However, due to significant heterogeneity in the included studies, interpretation of the summary data is difficult.     

Local treatment of empyema in children: a systematic review of randomized controlled trials

The aim of the study is to systematically evaluate data from randomized controlled trials (RCTs) on the efficacy of using intrapleural fibrinolytic agents in the treatment of complicated parapneumonic effusions or empyema in children. The Cochrane Library, MEDLINE and EMBASE databases were searched in July 2009. Four RCTs, involving 194 children, were included. In two RCTs, intrapleural fibrinolytic treatment was compared with normal saline. One of these RCTs showed a significantly reduced hospital stay in those treated with urokinase compared with those treated with normal saline. Otherwise, no fibrinolytic agent had an effect on any other outcome. Two RCTs that compared fibrinolytic treatment with video‐assisted thoracoscopic surgery (VATS) revealed no benefit of VATS. Conclusion: There is little evidence that intrapleural fibrinolysis is more effective than normal saline in the local treatment of complicated parapneumonic effusions or empyema in children. There is no evidence that VATS is more effective than fibrinolytic treatment. Only a limited number of trials were available for analysis, so some caution must be exercised in interpreting the strength of the evidence presented.     

Rheumatic fever in Nigerian children: a prospective study

The initial attack of acute rheumatic fever is hardly ever diagnosed in our environment. Most cases of acute rheumatic fever are seen during recurrent illness when cardiac damage is already severe and death from cardiac failure common. In the absence of effective primary prophylaxis against rheumatic fever in the foreseeable future it is important to find every case of acute rheumatic fever at the first attack, as on this would depend effective secondary prophylaxis and, hopefully, reduction of the morbidity and mortality rates. A prospective study was set up to achieve this aim. All cases suspected of having rheumatic fever among children seen at the Lagos University Teaching Hospital over a period of five years were subjected to the Jones' diagnostic criteria for diagnosis, and grouped into "Initial illness" and "Recurrent illness" groups. Twenty-one cases of acute rheumatic fever were diagnosed during the period, out of which ten (47.6%) were in the initial stage of the illness. There was a direct relationship between the severity of cardiac involvement and delay in recognition of the condition. It was concluded that efforts aimed at prompt recognition of the initial illness would be rewarding in minimising cardiac morbidity and mortality.     

Cisapride treatment for gastro-oesophageal reflux in children: a systematic review of randomized controlled trials

The aim of the systematic review was to determine the effect of cisapride compared with placebo or other non-surgical therapies for the treatment of symptoms of gastro-oesophageal reflux in children. We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, Science Citation Index and reference lists for randomized controlled trials which compared cisapride with placebo or other non-surgical therapy in children. We included only trials which reported reflux-related symptoms as an outcome, provided that cisapride was administered orally for at least I week. Seven trials (286 children in total) compared cisapride with placebo. Two trials reported good concealment of treatment allocation. The pooled odds ratio for the 'same or worse' symptoms was 0.34 (95% CI 0.10, 1.19). There was substantial heterogeneity between studies (P < 0.00001) and the funnel plot was asymmetrical. Adverse effects (mainly diarrhoea) were not significantly increased with cisapride (pooled odds ratio (OR) 1.80: 0.87, 3.70). The reflux index was significantly reduced in children treated with cisapride (weighted mean difference -6.49: -10.13, -2.85). One study (50 children) compared cisapride with gaviscon plus carobel: the OR for the 'same or worse' symptoms was 3.26 (0.93, 11.38). There was no clear evidence that cisapride reduced symptoms of gastro-oesophageal reflux. As smaller, poorer quality studies were biased in favour of a positive treatment effect, the pooled OR overestimated the potential benefits of cisapride. There was some evidence to suggest that gaviscon plus carobel may be a more effective option than cisapride.     

Ampicillin use in infant fever: a systematic review.

OBJECTIVES: To estimate the prevalence of perinatal Listeria monocytogenes and enterococcal infections in outpatient febrile infants and to evaluate the need to treat with ampicillin. DATA SOURCES: Online bibliographies were searched for articles related to serious bacterial infection and fever in infants. Reference lists from selected and review articles were also examined. STUDY SELECTION: Studies that reported rates and types of bacterial infection in febrile outpatients younger than 3 months were included. Those performed outside North America, lacking results by age, or those that evaluated selected patient populations were excluded. DATA EXTRACTION: Two authors independently reviewed the selected articles for inclusion and abstracted the data. DATA SYNTHESIS: Fourteen studies, evaluating 5247 febrile outpatients, were included. The prevalences of L monocytogenes and enterococcal infections were 7.3 (binomial exact 95% confidence interval [CI], 3.5-13.3), 1.9 (95% CI, 0.6-4.4), and 5.6 (95% CI, 0.7-2.1) per 1000 febrile infants in the first, second, and third months of life, respectively. To cover 1 infant with serious bacterial infection caused by L monocytogenes and enterococcal infections, the numbers of febrile infants who would need ampicillin were estimated as 138 (95% CI, 76-288) in the first month, 527 (95% CI, 226-1621) in the second month, and 178 (95% CI, 50-1469) in the third month. Enterococcal infections occurred in all ages studied; there were no Listeria infections after 30 days of age. CONCLUSION: The empirical use of ampicillin to cover febrile infants for L monocytogenes and enterococcal infections is most justifiable in the first month of life.     

拉莫三嗪单药治疗儿童癫癎的系统评价

目的 系统评价拉莫三嗪单药治疗儿童癫癎的有效性和安全性。方法 计算机检索PubMed、Cochrane 图书馆、CNKI、VIP、CBM、万方等中英文数据库,获得拉莫三嗪单药治疗儿童癫癎的随机对照试验。应用Cochrane 协作网推荐的方法进行文献筛选,资料提取和文献质量评估,采用RevMan 5.2软件进行Meta分析。结果 共纳入9个RCTs （1016例）。拉莫三嗪的癫癎发作完全控制率明显低于乙琥胺,与卡马西平和丙戊酸钠的差异均无统计学意义。拉莫三嗪的不良反应发生率明显低于卡马西平,与丙戊酸钠和乙琥胺的差异均无统计学意义;3种药物的退出率比较差异无统计学意义。结论 对于传统抗癫癎药物治疗无效、不良反应明显患儿,拉莫三嗪是一种较为理想的替代药物。但仍有待高质量、大样本及较长随访时间的随机对照试验予以证实。     

Updated systematic review and meta‐analysis of the predictive value of serum biomarkers in the assessment and management of fever during neutropenia in children with cancer

Routinely measurable biomarkers as predictors for adverse outcomes in febrile neutropenia could improve management through risk stratification. This systematic review assesses the predictive role of biomarkers in identifying events such as bacteraemia, clinically documented infections, microbiologically documented infection, severe sepsis requiring intensive care or high dependency care and death. This review collates 8319 episodes from 4843 patients. C‐reactive protein (CRP), interleukin (IL)‐6, IL‐8 and procalcitonin (PCT) consistently predict bacteraemia and severe sepsis; other outcomes have highly heterogeneous results. Performance of the biomarkers at admission using different thresholds demonstrates that PCT > 0.5 ng/mL offers the best compromise between sensitivity and specificity: sensitivity 0.67 (confidence interval [CI] 0.53‐0.79) specificity 0.73 (CI 0.66‐0.77). Seventeen studies describe the use of serial biomarkers, with PCT having the greatest discriminatory role. Biomarkers, potentially with serial measurements, may predict adverse outcomes in paediatric febrile neutropenia and their role in risk stratification is promising.     

Oral gatifloxacin in the outpatient treatment of children with cancer fever and neutropenia

BACKGROUND: Fever in neutropenic (FN) patients requires immediate broad-spectrum antibiotics, however, such patients do not represent a homogeneous population and the majority of them are at low risk of developing complication. Gatifloxacin (GA) is an alternative, though it has not been thoroughly studied in Pediatrics yet. The aim of this study was to evaluate oral GA in oncology pediatric patients with FN and low risk of infectious complications. METHODS: We conducted a prospective study in patients submitted to chemotherapy and FN, from the ages of 3 to 21 years old, with solid tumors, acute lymphoid leukemia, and lymphomas without comorbidities and treated as outpatient with oral GA. Safety and adverse effects were monitored. RESULTS: We evaluated 108 patients with 201 episodes of FN. The average age was 10.8 years, 64.8% of the patients were male. Osteosarcoma accounted for 22% of the episodes, rhabdomyosarcoma for 13%, acute lymphoid leukemia, lymphomas and Ewing sarcoma, for 11% each. Among the 174 episodes exclusively treated as outpatients, the average duration of neutropenia was 4.8 days, the average duration of fever was 2.4 days; the average duration of the treatment was 8.1 days. The treatment was successful in 75.9%, analyzing only the first episodes. No patient died during the study. Adverse events included diarrhea, vomiting, increased liver enzymes, arthralgia, and ECG changes. CONCLUSION: Oral GA is effective and safe in the management of oncology pediatric patients with FN at low risk of infectious complications in the outpatient setting.     

小儿急性胰腺炎的文献研究

目的探讨小儿急性胰腺炎（CAP）的病因及防治措施。方法通过检索中文科技期刊全文数据库1989-2003年CAP的文献57篇,建立纳入和排除标准,对纳入符合要求的文献,统计分析其报道的病例数、性别、年龄、诱因、并发症、治疗、预后等临床资料。结果符合纳入和排除标准的共36篇,478例,男256例,女224例;年龄6个月～14岁。CAP好发于学龄儿童（70．50％）,特发性占33．05％,腮腺病毒感染占21．76％,高脂饮食占17．15％,蛔虫病占9．62％。非手术治疗,病死率为1．22％,其中,中西医结合治疗117例,无1例病死．外科手术治疗,病死率为14．49％。结论腮腺炎、高脂饮食和胆道蛔虫症是CAP的主要病因,减少腮腺炎和胆道蛔虫症发病是预防CAP的关键,以中西医结合为主要的非手术治疗及正确掌握手术指征是治疗的有效途径。     

Acyclovir for treating varicella in otherwise healthy children and adolescents: a systematic review of randomised controlled trials

Background  

Acyclovir has the potential to shorten the course of chickenpox which may result in reduced costs and morbidity. We conducted a systematic review of randomised controlled trials that evaluated acyclovir for the treatment of chickenpox in otherwise healthy children.     

Episodes of fever and neutropenia in children with cancer in a tertiary care medical center in Turkey

The aim of this study was to determine the clinical features and microbiological spectrum during episodes of fever and neutropenia (FEN) in children with cancer. Demographics, clinical information, treatment approaches, and outcomes of the patients admitted to Akdeniz University Department of Pediatric Hematology and Oncology from October 1996 to June 2004 were evaluated retrospectively. Of the total 621 episodes, 345 (55.5%) were microbiologically documented (MDI) (36.4%) or clinically suspected (CSI) (19.2%) infections. A total of 425 infections were diagnosed in 345 episodes, in which lower respiratory tract infections were the most common (32.7%). Among the microbiologically documented infections, Staphylococci (both coagulase-negative and coagulase-positive) (38.7%) and Escherichia coli (12.9%) were the most frequently isolated gram-positive and gram-negative organisms, respectively. Monocytopenia less than 100/microL (p = 0.01), duration of neutropenia (p = .01) and fever (p < .001) were significantly associated with documented infection by univariate analysis. In addition, presence of previous FEN episode (p = .001) and hypotension (p = .029) were also found to be risk factors. However, using the multivariate analyses, only the duration of fever was found to be an independent risk factor for MDI. The rate of mortality was significantly higher among under 1-year-old patients (p = .039). Hypotension and uncontrolled cancer were the significant determinants of poor prognosis. These results may help to consider a more selective management strategy for children with these problems.     

Immunotherapy in children and adolescents with allergic rhinoconjunctivitis: a systematic review

Allergen‐specific immunotherapy is one of the cornerstones of allergic rhinoconjunctivitis treatment. Since the development of non‐invasive administration forms with better safety profiles, there is an increasing tendency to prescribe immunotherapy in youngsters. However, no overview is available on the efficacy of immunotherapy in all its different administration forms in youngsters. Therefore, we systematically reviewed randomized controlled trials (RCTs) to evaluate the effect of immunotherapy with inhalant allergens on symptoms and medication use in children and adolescents with allergic rhinoconjunctivitis. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register and reference lists of recent reviews and published trials were searched. RCTs including youngsters aged 0–18 yr with allergic rhinoconjunctivitis and comparing immunotherapy with placebo, symptomatic treatment or a different administration form of immunotherapy were included. Primary outcome measures were rhinoconjunctivitis symptom and/or medication scores. Methodological quality was assessed using the validated Delphi list. A method of best evidence synthesis, a rating system with levels of evidence based on the overall quality and the outcome of the trials, was used to assess efficacy. Six subcutaneous (SCIT), four nasal (LNIT), seven oral (OIT) and 11 sublingual (SLIT) immunotherapy trials, comprising 1619 youngsters, were included. Only 39% of the trials were of high methodological quality. For the SCIT and OIT subgroups the level of evidence for efficacy was conflicting. Moderate evidence of effect was found for LNIT. Analysis of the SLIT subgroup showed no evidence of effect. The evidence for the perennial and seasonal allergen trials within the subgroups varied from moderate evidence of effect to no evidence of effect. In conclusion, there is at present insufficient evidence that immunotherapy in any administration form has a positive effect on symptoms and/or medication use in children and adolescents with allergic rhinoconjunctivitis.