What is the risk of infectious complications in pediatric oncology patients due to prolonged immune suppression from intensive chemotherapy regimens, and how can confirmation of an infectious pathology guide management, including choice of antimicrobial therapy and duration of treatment?

From the Guidelines

Pediatric oncology patients undergoing intensive chemotherapy should receive systemic antibacterial prophylaxis only when the risk of infection is high, such as in cases of acute myeloid leukemia and relapsed acute lymphoblastic leukemia (ALL), as recommended by the most recent guideline 1. When infection is suspected, prompt diagnostic confirmation is essential to guide appropriate management. Blood cultures should be obtained immediately when fever develops, with at least two sets collected from different sites or lumens if a central line is present. Additional cultures from urine, respiratory secretions, stool, or specific sites of suspected infection should be collected based on clinical presentation. Empiric broad-spectrum antibiotics should be initiated promptly, typically including an antipseudomonal beta-lactam such as piperacillin-tazobactam or cefepime. For patients with severe sepsis, hemodynamic instability, or suspected resistant organisms, addition of an aminoglycoside or glycopeptide may be warranted. Some key points to consider in the management of these patients include:

• The use of levofloxacin as prophylaxis during severe neutropenia 1
• The importance of regular reassessment of the patient's clinical status and laboratory parameters to adjust therapy accordingly
• The need to minimize antibiotic resistance while ensuring effective treatment of infections in these vulnerable patients
• The consideration of systemic antifungal prophylaxis in pediatric patients with cancer and hematopoietic stem-cell transplantation recipients, as they are at high risk for invasive fungal disease (IFD) 1

From the FDA Drug Label

1.2 Empiric Therapy for Febrile Neutropenic Patients

Cefepime Injection as monotherapy is indicated for empiric treatment of febrile neutropenic patients In patients at high risk for severe infection (including patients with a history of recent bone marrow transplantation, with hypotension at presentation, with an underlying hematologic malignancy, or with severe or prolonged neutropenia), antimicrobial monotherapy may not be appropriate Insufficient data exist to support the efficacy of cefepime monotherapy in such patients [see Clinical Studies (14)].

The Cefepime Injection is indicated for empiric treatment of febrile neutropenic patients. However, in patients at high risk for severe infection, such as those with underlying hematologic malignancy or severe or prolonged neutropenia, antimicrobial monotherapy may not be appropriate due to insufficient data to support its efficacy in these cases 2.

From the Research

Empirical Antibiotic Therapy in Pediatric Oncology Patients

• The use of empirical antibiotic therapy is widely accepted for patients with fever and neutropenia during cancer chemotherapy 3.
• Studies have compared the efficacy and safety of different antibiotic regimens, including cefepime monotherapy versus ceftriaxone plus amikacin 3, cefepime versus ceftazidime 4, and piperacillin/tazobactam versus cefepime 5, 6.
• These studies have shown that monotherapy with broad-spectrum antibiotics, such as cefepime or piperacillin/tazobactam, is as effective and safe as combination therapy for initial empirical treatment of febrile neutropenia in pediatric cancer patients 3, 4, 5, 6.

Choice of Antimicrobial and Duration of Therapy

• The choice of antimicrobial therapy should be based on the individual patient's risk factors, including the type of cancer, the intensity of chemotherapy, and the presence of any underlying medical conditions 3, 4, 5, 6.
• The duration of therapy should be guided by the patient's clinical response, including the resolution of fever and the recovery of neutrophil counts 3, 4, 5, 6.
• In general, therapy should continue until the patient's neutrophil count recovers to a safe level, usually above 500 cells/mm^3 3, 4, 5, 6.

Management of Pediatric Oncology Patients in the ICU

• Pediatric oncology patients who require admission to the intensive care unit (ICU) often have complex medical needs, including oncological emergencies and decompensation from treatment and its side effects 7.
• ICU physicians should be aware of the unique challenges and considerations involved in caring for these patients, including the need for close monitoring and prompt intervention to prevent and manage complications 7.