Neutropenia febril en niños con cáncer: manejo en el servicio de emergencias / Febrile neutropenia in cancer patients: management in the emergency room

Resumen La neutropenia febril es una condición que puede amenazar la vida y que requiere de atención inmediata, particularmente en pacientes en que la misma está asociada a tratamientos con quimioterapia. Estos pacientes tienen un riesgo mucho mayor de desarrollar enfermedades bacterianas, y en ellos, la fiebre puede ser el único indicador de enfermedad bacteriana grave. El manejo adecuado de la neutropenia febril da énfasis en la identificación pronta de los pacientes, estratificación del riesgo y antibioterapia iniciada durante los primeros 60 min del ingreso al servicio de emergencias. No todos los niños con neutropenia febril conllevan el mismo riesgo de morbi-mortalidad, por lo que en los últimos años se han hecho esfuerzos para distinguir entre pacientes de alto riesgo en quienes se recomienda el manejo hospitalario más agresivo. En pacientes que se clasifican como de bajo riesgo se puede considerar el manejo ambulatorio inicial o después de 72 h, mientras que en aquellos de alto riesgo se recomienda hospitalizar y manejar con antimicrobianos parenterales.

Febrile neutropenia is a life-threatening condition that requires immediate attention, especially in patients with chemotherapy-related neutropenia. Patients with febrile neutropenia have a much greater risk of developing bacterial disease, and fever may be the only indicator of severe bacterial infection. Adequate management of febrile neutropenia emphasizes early recognition of patients, risk stratification, and antibiotic therapy administration during the first 60 minutes of admission to an emergency room. Not all children with febrile neutropenia carry the same risk of morbidity and mortality, so in recent years, efforts have been made to distinguish between high-risk patients where more aggressive hospital management is required. In children classified as low-risk, outpatient management may be considered initially or after 72 hours, whilst high-risk patients should be hospitalized and managed with parenteral antibiotics.

Patterns of Neutropenia and Risk Factors for Febrile Neutropenia of Diffuse Large B-Cell Lymphoma Patients Treated with Rituximab-CHOP

Febrile neutropenia (FN) is the major toxicity of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen in the treatment of diffuse large B-cell lymphoma (DLBCL). The prediction of neutropenia and FN is mandatory to continue the planned R-CHOP therapy resulting in successful anti-cancer treatment. The clinical features and patterns of neutropenia and FN from 181 DLBCL patients treated with R-CHOP were analyzed retrospectively. Sixty percent (60.2%) of patients experienced at least one episode of grade 4 neutropenia. Among them, 42.2% of episodes progressed to FN. Forty-eight percent (48.8%) of patients with FN was experienced their first FN during the first cycle of R-CHOP. All those patients never experienced FN again during the rest cycles of R-CHOP. Female, higher stage, international prognostic index (IPI), age > or =65 yr, comorbidities, bone marrow involvement, and baseline serum albumin < or =3.5 mg/dL were significant risk factors for FN by univariate analysis. Among these variables, comorbidities (P=0.009), bone marrow involvement (P=0.006), and female gender (P=0.024) were independent risk factors for FN based on multivariate analysis. On observing the patterns of neutropenia and FN, primary prophylaxis of granulocyte colony-stimulating factor (G-CSF) and antibiotics should be considered particularly in female patients, patients with comorbidities, or when there is bone marrow involvement of disease.

Rhizobium radiobacter recovered from blood of a pediatric patient with stem cell transplantation: a case report and characterization of antimicrobial susceptibility profile

Rhizobium radiobacter is an uncommon agent of infection and has been associated with indwelling intravascular devices such as catheter in immunocompromised patients. Here, we report a case of R. radiobacter recovered from blood cultures in stem cell transplantation in a pediatric patient and present an extensive characterization of its antimicrobial susceptibility profile. The isolate presented low MICs to many antimicrobial agents, but high MICs to ceftazidime, piperacillin-tazobactam, aztreonam, and fosfomycin.

Tratamento antimicrobiano em crianças com câncer durante a quimioterapia: revisão de 830 episódios de neutropenia febril / Antimicrobial treatment in children with febrile neutropenia during the chemotherapy – a review of 830 episodes

Proposta: Revisar todos os episódios de neutropenia febril ocorridos em um período de 4 anos em uma única instituição. Comparar os nossos achados com a literatura médica mundial. Materiais e métodos: Entre janeiro de 2000 e dezembro de 2003, analisamos retrospectivamente 830 episódios de neutropenia febril ocorridos nos pacientes pediátricos menores de 18 anos admitidos no Departamento de Pediatria do Hospital do Câncer de São Paulo, Brasil. Resultados: A população pediátrica portadora de neoplasia em vigência de tratamento quimioterápico foi caracterizada quanto a idade, sexo, raça, características clínicas e laboratoriais ao momento da admissão hospitalar, tratamento e evolução dos episódios de neutropenia febril. A mortalidade atribuída à infecção ocorreu somente em 4% do grupo estudado. Conclusão: Conhecer as peculiaridades da população de crianças portadoras de câncer de uma instituição serve para a reorganização da abordagem por parte do corpo clínico e para a revisão da eficácia do tratamento medicamentoso

Purpose: To review all episodes of febrile neutropenia registered during a period of 4 years in a single Institution and compare the results with the world’s medical literature. Methods and materials: A total of 830 episodes of febrile neutropenia in <18-years old pediatric patients admitted to the Pediatrics Department of Hospital do Câncer de São Paulo, Brazil, in the period between January 2000 and December 2003, were retrospectively analyzed. Results: The pediatric cancer patients under chemotherapy were characterized for age, sex, race, clinical and laboratorial characteristics at admission, treatment and evolution of febrile neutropenia episodes. A mortality rates of 4% was attributed to infection. Conclusion: The characterization of a population of pediatric cancer patients in an Institution is important for the reorganization of clinical team approaches, and for reviewing the efficiency of drug therapy