Systematic review of reduced therapy regimens for children with low risk febrile neutropenia

PURPOSE: Reduced intensity therapy for children with low-risk febrile neutropenia may provide benefits to both patients and the health service. We have explored the safety of these regimens and the effect of timing of discharge. METHODS: Multiple electronic databases, conference abstracts and reference lists were searched. Randomised controlled trials (RCT) and prospective observational cohorts examining the location of therapy and/or the route of administration of antibiotics in people younger than 18 years who developed low-risk febrile neutropenia following treatment for cancer were included. Meta-analysis using a random effects model was conducted. I (2) assessed statistical heterogeneity not due to chance. Registration: PROSPERO (CRD42014005817). RESULTS: Thirty-seven studies involving 3205 episodes of febrile neutropenia were included; 13 RCTs and 24 prospective observational cohorts. Four safety events (two deaths, two intensive care admissions) occurred. In the RCTs, the odds ratio for treatment failure (persistence, worsening or recurrence of fever/infecting organisms, antibiotic modification, new infections, re-admission, admission to critical care or death) with outpatient treatment was 0.98 (95% confidence interval (95%CI) 0.44-2.19, I (2) = 0 %) and with oral treatment was 1.05 (95%CI 0.74-1.48, I (2) = 0 %). The estimated risk of failure using outpatient therapy from all prospective data pooled was 11.2 % (95%CI 9.7-12.8 %, I (2) = 77.2 %) and using oral antibiotics was 10.5 % (95%CI 8.9-12.3 %, I (2) = 78.3 %). The risk of failure was higher when reduced intensity therapies were used immediately after assessment, with lower rates when these were introduced after 48 hours. CONCLUSIONS: Reduced intensity therapy for specified groups is safe with low rates of treatment failure. Services should consider how these can be acceptably implemented

Predicting Infectious ComplicatioNs in Children with Cancer : an external validation study

Background:The aim of this study was to validate the 'Predicting Infectious ComplicatioNs in Children with Cancer' (PICNICC) clinical decision rule (CDR) that predicts microbiologically documented infection (MDI) in children with cancer and fever and neutropenia (FN). We also investigated costs associated with current FN management strategies in Australia.Methods:Demographic, episode, outcome and cost data were retrospectively collected on 650 episodes of FN. We assessed the discrimination, calibration, sensitivity and specificity of the PICNICC CDR in our cohort compared with the derivation data set.Results:Using the original variable coefficients, the CDR performed poorly. After recalibration the PICNICC CDR had an area under the receiver operating characteristic (AUC-ROC) curve of 0.638 (95% CI 0.590-0.685) and calibration slope of 0.24. The sensitivity, specificity, positive predictive value and negative predictive value of the PICNICC CDR at presentation was 78.4%, 39.8%, 28.6% and 85.7%, respectively. For bacteraemia, the sensitivity improved to 85.2% and AUC-ROC to 0.71. Application at day 2, taking into consideration the proportion of MDI known (43%), further improved the sensitivity to 87.7%. Length of stay is the main contributor to cost of FN treatment, with an average cost per day of AUD 2183 in the low-risk group.Conclusions:For prediction of any MDI, the PICNICC rule did not perform as well at presentation in our cohort as compared with the derivation study. However, for bacteraemia, the predictive ability was similar to that of the derivation study, highlighting the importance of recalibration using local data. Performance also improved after an overnight period of observation. Implementation of a low-risk pathway, using the PICNICC CDR after a short period of inpatient observation, is likely to be safe and has the potential to reduce health-care expenditure

A Canadian Perspective on the Subcutaneous Administration of Rituximab in Non-Hodgkin Lymphoma

Rituximab is widely used for the treatment of non-Hodgkin lymphoma, being a key component in most therapeutic regimens. Administration of the intravenous (IV) formulation is lengthy and places a significant burden on health care resources and patient quality of life. A subcutaneous (sc) formulation that provides a fixed dose of rituximab is being examined in a number of studies. Results indicate that the pharmacokinetics are noninferior and response rates are comparable to those obtained with the IV formulation. Moreover, the sc formulation is preferred by patients and health care providers and reduces administration and chair time. Additional advantages include a lesser potential for dosing errors, shorter preparation time, reduced drug wastage, and fewer infusion-related reactions. Despite the success of the sc formulation, correct administration is needed to reduce administration-related reactions. By using a careful procedure, the sc formulation can be given safely and effectively, potentially reducing the burden on health care resources and improving quality of life for patients

Essential medicines for pediatric oncology in developing countries

The burden of cancer in children in low and middle income countries (LMICs) is substantial, comprising at least 80% of incident cases globally, and an even higher proportion of cancer-related deaths. With survival rates exceeding 80% in high income countries, it is imperative to transfer these successes to LMICs. A major challenge is the poor availability of safe, cost-effective chemotherapy. A list of 51 drugschemotherapeutics, infectious disease agents, and supportive care medicationsis proposed as essential to improving the survival of children with cancer in LMICs with an additional 13 drugs identified as being of further value. Pediatr Blood Cancer 2013; 60: 889891. (c) 2013 Wiley Periodicals, Inc.Baylor Coll Med, Dept Pediat, Hematol Oncol Sect, Houston, TX 77030 USABaylor Coll Med, Dept Pediat, Hematol Oncol Sect, Gaborone, BotswanaMcMaster Childrens Hosp, Hamilton, ON, CanadaUniversidade Federal de São Paulo, Sch Med, Pediat Oncol Inst, São Paulo, BrazilMcMaster Univ, Dept Pediat, Hamilton, ON, CanadaMcMaster Univ, Dept Pathol, Hamilton, ON, CanadaMcMaster Univ, Dept Med, Hamilton, ON, CanadaUniversidade Federal de São Paulo, Sch Med, Pediat Oncol Inst, São Paulo, BrazilWeb of Scienc

A formulary for pediatric oncology in developing countries

McMaster Univ, Hlth Sci Ctr, Dept Pediat, Hamilton, ON L8S 4J9, CanadaMcMaster Childrens Hosp, Hamilton, ON, CanadaUniv Milan, Pediat Clin, Monza, ItalyHosp Pediat Prof JP Garrahan, Buenos Aires, DF, ArgentinaUnidad Nacl Oncol Pediat, Guatemala City, GuatemalaHosp Pereira Rossell, Montevideo, UruguayInst Oncol Pediat, São Paulo, BrazilClin Las Condes, Santiago, ChileSt Jude Childrens Res Hosp, Memphis, TN 38105 USABJ Wadia Hosp Children, Bombay, Maharashtra, IndiaUniv Stellenbosch, Dept Pediat & Child Hlth, ZA-7505 Tygerberg, South AfricaWeb of Scienc