Assessment of Antimicrobial Prescription Pattern among Paediatric Cancer Patients with Febrile Neutropenia

Abstract

Febrile neutropenia (FN) is the most common haematological toxicity associated with cytotoxic chemotherapy. Individual studies are available, but national estimates on FN are required. To describe chemotherapy-induced neutropenia, its associated infection-causing organisms, and the antimicrobials prescribed, a prospective cum retrospective study was conducted for a period of 9 months, which included 50 paediatric cancer patients less than 18 years. Patients having an absolute neutrophil count (ANC) less than 1500/mm 3 , having body temperature of above 38.5°C, and receiving anti-infectives as prophylaxis were included. Patient demographic details, presenting complaints, absolute neutrophil count, and laboratory findings were noted in a patient proforma. Out of the overall 584 episodes of CIN, 188 episodes (32.2%) were of febrile neutropenia. Majority of patients were boys (70%), aged between 1 and 6 years (66%), and diagnosed with acute lymphoblastic leukemia (64%). The mean ANC was 765.6 ± 235.7 × 10 9 /l. From a total of 188 episodes of FN, in 179 episodes, patients had ANC < 500 mm 3 , whereas in 9 episodes, patients had ANC < 100 mm 3. The predominant site of infection in these patients was bloodstream (27%), followed by urine (6%) and stool (1%). From the 51 episodes of blood culture done, the highest reported was of Staphylococcus species (49.01%). Anti-infective combinations of piperacillin/vancomycin (56%) and piperacillin/amikacin (42%) were given. Patients with positive fungal growth received Inj. amphotericin (18%) as therapy. Majority of the children undergoing chemotherapy, diagnosed with ALL, had FN. Low ANC led them susceptible to various bacterial and fungal infections. Introduction to antimicrobials and antifungals have all contributed to decreasing chemotherapy-related infections.

Chemotherapy Induced Neutropenic Fever and Its Response to Empirical Antimicrobial Therapy

“…It showed 82% efficacy in imipenem and 59% in ceftazidime plus vancomycin group. 14 In a study conducted by Abraham et al, at Bharati hospital, Pune in 2019; 32% of paediatric patients suffered from febrile neutropenia and Staphylococcus species (49%) were the most common one which was positive in blood culture, 15 however in our study most of the cultures were negative and only two culture were positive for S. aureus.…”

“…Besides mucositis and mucormycosis no fungal infection was documented in our study, which is comparable to other studies. 15 Invasive fungal infections contribute significant morbidity and mortality in neutropenic patients on chemotherapy. Thus, a delay in treatment while establishing a diagnosis leads to increased morbidity and mortality.…”

Gaps in diagnosing suspected infection in immunocompromised children with cancer: A systematic review

“…The included studies were from diverse regions globally, with six (18%) conducted in the United States 2,11–15 and 28 (82%) studies in other countries (Africa, n = 1 [3%]; Asia, n = 15 [44%]; Oceania, n = 2 [6%]; Europe, n = 4 [12%]; Middle East, n = 4 [12%]; Central America, n = 1 [3%]; South America, n = 1 [3%]) 16–43 (Figure S2). Majority ( n = 21, 62%) 2,11,12,16,18,19,21,25,26,28–35,38,39,42,43 of studies utilized standard culture methods, while a smaller number ( n = 8, 24%) 13,14,20,22–24,27,41 of studies reported on newer methods such as metagenomic sequencing and PCR diagnostics (i.e., qPCR [including singleplex and multiplex], 22,23 panfungal real‐time PCR, 27 16S rRNA gene PCR, 23,24 respiratory viral panel PCR, 13,20,41 and Pneumocystis jirovecii PCR 20 ). Other assessed tests or studies included histopathology examination, 15 Aspergillus galactomannan antigen assay (GM), 15,17,20,27 (1‐3)‐β‐D‐glucan assay (BDG), 15,27 and procalcitonin and C‐reactive protein biomarkers 37 .…”

“…Twenty-four studies reported on the clinical course, including antimicrobial therapy. 2,11,12,[14][15][16][17][18][19][20][21]23,25,29,30,33,[35][36][37][38][39][40][41]43 The diagnostic impact on antimicrobial use was reported in only three studies. Two studies assessed the diagnostic impact of using samples from invasive procedures (i.e., BAL and video-assisted thoracoscopic surgery-biopsy) and determined that using such samples led to a change in antimicrobial management in 20.6%−49.5% 15,20 and 64.5% 15 of the cases with suspected infections, respectively.…”

Bacteriological Spectrum and Antimicrobial Sensitivity of Pathogens in Children with Hematologic Malignancies and Febrile Neutropenia Research

“…Traditionally, Gram-negative bacte-ria were known as the primary causative agent of BSI in FN patients. Throughout the 1980s and 1990s, there was a decreasing incidence of Gram-negative bacteria accompanied by a relative increase in Gram-positive infection; a change attributed to factors such as better management of Gram-negative infections, prescription of prophylactic fluoroquinolones, and increased use of intravenous catheters (4,5). The current situation of distribution of bacteria in pediatric FN in our community is controversial.…”