Objective: To compare the use of intravenous vs. oral antibiotic therapy. Methods:All febrile neutropenic patients younger than 18 years old with low risk of complications and receiving chemotherapy were selected. The study was conducted from 2002 to 2005 at the Pediatric Oncology Unit of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. Patients were divided into group A and group B and were randomly assigned to receive oral or intravenous therapy. The empirical antimicrobial treatment used for group A consisted in oral ciprofloxacin plus amoxicillin-clavulanate and intravenous placebo, and group B received cefepime and oral placebo.Results: A total of 91 consecutive episodes of febrile neutropenia in 58 children were included in the study. For patients of group A, treatment failure rate was 51.2%; the mean length of hospital stay was 8 days (range 2-10 days). For patients treated with intravenous antibiotic therapy, treatment failure rate was 45.8%; the mean length of hospital stay was 7 days (range 3-10 days).

Objective: To compare the use of intravenous vs. oral antibiotic therapy. Methods:All febrile neutropenic patients younger than 18 years old with low risk of complications and receiving chemotherapy were selected. The study was conducted from 2002 to 2005 at the Pediatric Oncology Unit of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. Patients were divided into group A and group B and were randomly assigned to receive oral or intravenous therapy. The empirical antimicrobial treatment used for group A consisted in oral ciprofloxacin plus amoxicillin-clavulanate and intravenous placebo, and group B received cefepime and oral placebo.Results: A total of 91 consecutive episodes of febrile neutropenia in 58 children were included in the study. For patients of group A, treatment failure rate was 51.2%; the mean length of hospital stay was 8 days (range 2-10 days). For patients treated with intravenous antibiotic therapy, treatment failure rate was 45.8%; the mean length of hospital stay was 7 days (range 3-10 days). Conclusion:There was no difference in the outcome in oral vs. intravenous therapy. There is need of larger randomized trials before oral empirical therapy administered to this population should be considered the new standard of treatment. No conflicts of interest declared concerning the publication of this article. 532 Jornal de Pediatria -Vol. 85, No. 6, 2009 Oral vs. intravenous antimicrobial therapy -Cagol AR et al. J Pediatr (Rio J)those at a higher risk of complications and those with good prognosis who usually present with quick fever reduction without severe complications. The identification of these factors may help to personalize treatment according to the risk factors of the febrile episode.

Li a recente publicação no jornal com grande interesse 1 . Cagol et al. concluíram que "não houve diferença no desfecho entre a terapia oral versus intravenosa" 1 . Há algumas preocupações e questões sobre esse relato. Primeiramente, ainda é preciso explicar se o número de sujeitos é estatisticamente aceitável e se há alguma diferença de histórico entre os sujeitos nos dois grupos. Em segundo lugar, deve-se esclarecer que "não houve diferença no desfecho" relaciona-se à eficácia da alternativa terapêutica. No entanto, não há dados sobre custo-efetividade e custo-utilidade. Estudos posteriores sobre esses aspectos são necessários. 0021-7557/10/86-03/254 Jornal de PediatriaCopyright © 2010 by Sociedade Brasileira de Pediatria Viroj WiwanitkitProfessor, Wiwanitkit House, Bangkhae, Bangkok, Tailândia 10160.doi:10.2223/JPED.2018Não foram declarados conflitos de interesse associados à publicação desta carta. Resposta dos autoresAgradecemos ao Professor Wiwanikit por seus comentários sobre nosso artigo. O Professor Wiwanikit deseja saber se houve diferenças de histórico entre os dois grupos de pacientes e se o número de pacientes em cada grupo permite uma interpretação estatisticamente aceitável. Não houve diferença aparente entre os pacientes nos dois grupos em termos de idade, gênero, grau de neutropenia, situação da doença e presença de comorbidades. De fato, não encontramos diferenças no desfecho de pacientes que receberam terapia oral versus intravenosa. Entretanto, destacamos, no artigo, que um ensaio clínico prospectivo conduzido por grupo cooperativo com um grande número de pacientes ainda é necessário antes de fazer uma recomendação definitiva sobre o uso seguro de terapia oral para pacientes neutropênicos febris (N&F). Em nosso artigo, também fizemos referência a outros estudos sugerindo que pacientes N&F de baixo risco podem ser tratados com êxito como pacientes ambulatórios. Acreditamos que existam limitações quanto a uma implementação mais ampla dessa abordagem, que inclui presença de comorbidades médicas, barreiras sociais e uso concomitante de protocolos de quimioterapia de alta intensidade. Além disso, pode haver alguma relutância por parte de médicos em assumir riscos adicionais, sabendo que a prática estabelecida de tratamento ambulatorial de pacientes N&F tem uma taxa de mortalidade muito baixa. Algemir Brunetto

Standard of care and protocols for the treatment of pediatric cancer lead to a clear improvement in survival rates and quality of life. Little is known about how these treatments are implemented in Brazil. Our study aimed to evaluate children treated for Hodgkin disease (HD) in south Brazil between 2002 and 2013 through the analysis of medical records in 6 different centers.Results: Fifty-nine children and adolescents were included. The median age was 12 years (range 3-18 years). Male:female ratio was 1.95:1. Localized disease (stage I/II) was observed in 30 patients (50.8%) while the remaining 29 (49.2%) had advanced disease (Stage III/IV).The chemotherapeutic treatment schema was different among services and comprised three different based protocols. ABVD schema was the most frequently used (52 children (88.1%)).The number of cycles was highly variable (4-16 cycles) even at the same clinical stage and with similar clinical response.Conclusion: These data highlight the importance of turning the "best practice policies" readily available to all pediatric oncologists. Local protocols allow integrative studies among centers that would certainly maintain or improve cure rates, reduce long-term toxicity and evaluate specific biological characteristics of these diseases in our population. For these reasons, we reinforce the idea that standardization of treatment in pediatric oncology is a child health priority and also a viable low-cost strategy to improve care in middle-income countries such as Brazil .