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      Guidance Statement for the Management of Febrile Neutropenia in Pediatric Patients Receiving Cancer-Directed Therapy in Central America and the Caribbean

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          Abstract

          PURPOSE

          Our objective was to provide regionally appropriate, resource-conscious recommendations for the diagnosis and treatment of pediatric patients with febrile neutropenia.

          METHODS

          A multinational panel of Central American and Caribbean clinicians who deliver pediatric oncology care prioritized clinically important questions and then used the Grading of Recommendations Assessment, Development and Evaluation methodology to provide recommendations on the selected topics.

          RESULTS

          Twenty-two questions and 2 definitions were included in the guideline, which was intended to establish minimum care standards for pediatric patients treated in regional centers. Of all the included studies, 6.9% were conducted in low- and middle-income countries, and no studies were performed in countries represented on the panel.

          CONCLUSION

          The panel made recommendations on the basis of existing evidence but identified important gaps in knowledge from the region and from resource-limited settings that may affect the clinical applicability of these recommendations. These deficiencies suggest a research agenda that will enable future guidelines to be more responsive to the local context.

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          Most cited references33

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          Guideline for the Management of Fever and Neutropenia in Children With Cancer and Hematopoietic Stem-Cell Transplantation Recipients: 2017 Update.

          Purpose To update a clinical practice guideline (CPG) for the empirical management of fever and neutropenia (FN) in children with cancer and hematopoietic stem-cell transplantation recipients. Methods The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group of experts in pediatric oncology and infectious diseases that includes a patient advocate. For questions of risk stratification and evaluation, we updated systematic reviews of observational studies. For questions of therapy, we conducted a systematic review of randomized trials of any intervention applied for the empirical management of pediatric FN. The Grading of Recommendation Assessment, Development and Evaluation approach was used to make strong or weak recommendations and to classify levels of evidence as high, moderate, low, or very low. Results Recommendations related to initial presentation, ongoing management, and empirical antifungal therapy of pediatric FN were reviewed; the most substantial changes were related to empirical antifungal therapy. Key differences from our 2012 FN CPG included the listing of a fourth-generation cephalosporin for empirical therapy in high-risk FN, refinement of risk stratification to define patients with high-risk invasive fungal disease (IFD), changes in recommended biomarkers and radiologic investigations for the evaluation of IFD in prolonged FN, and a weak recommendation to withhold empirical antifungal therapy in IFD low-risk patients with prolonged FN. Conclusion Changes to the updated FN CPG recommendations will likely influence the care of pediatric patients with cancer and those undergoing hematopoietic stem-cell transplantation. Future work should focus on closing research gaps and on identifying ways to facilitate implementation and adaptation.
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            Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation.

            To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN). The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations. Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented. This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.
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              Differential time to positivity: a useful method for diagnosing catheter-related bloodstream infections.

              Catheter-related bloodstream infections are associated with recognized morbidity and mortality, especially in critically ill patients. Accurate diagnosis of such infections results in proper management of patients and in reducing unnecessary removal of catheters. To evaluate differential time to positivity as a method for diagnosing catheter-related bacteremias caused by both short-term and long-term use of central venous catheters. Prospective study design. M.D. Anderson Cancer Center, Houston, Texas, a tertiary care cancer center. All patients, between September 1999 and November 2000, who had the same organism isolated from blood cultures drawn simultaneously through the central venous catheter and the peripheral vein. Time necessary for the blood cultures from the central venous catheter and the peripheral vein to become positive, as well as other relevant patient information. 191 bloodstream infections with positive simultaneous central venous catheter and peripheral vein blood cultures were included. One hundred eight patients had catheter-related bacteremias, and 83 had non-catheter-related bacteremias. Catheter-related bacteremias were more frequently caused by staphylococci and less likely to be associated with underlying hematologic malignant conditions, neutropenia, and longer duration of hospitalization. As a diagnostic tool for catheter-related bacteremia (using a composite definition reference standard according to the Infectious Diseases Society of America guidelines), differential time to positivity of 120 minutes or more was associated with 81% sensitivity and 92% specificity for short-term catheters and 93% sensitivity and 75% specificity for long-term catheters. Differential time to positivity of 120 minutes or more is highly sensitive and specific for catheter-related bacteremia in patients who have short- and long-term catheters.
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                Author and article information

                Journal
                JCO Glob Oncol
                JCO Glob Oncol
                go
                go
                GO
                JCO Global Oncology
                American Society of Clinical Oncology
                2687-8941
                2020
                27 March 2020
                : 6
                : JGO.19.00329
                Affiliations
                [ 1 ]Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
                [ 2 ]Department of Internal Medicine, University of South Florida, Tampa, FL
                [ 3 ]Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
                [ 4 ]Hospital Nacional de Niños Dr. Carlos Sáenz Herrera, San José, Costa Rica
                [ 5 ]Hospital Infantil Dr Robert Reid Cabral, Santo Domingo, Dominican Republic
                [ 6 ]Hospital Infantil Manuel de Jesus Rivera “La Mascota,” Managua, Nicaragua
                [ 7 ]Hospital del Niño Dr José Renán Esquivel, Panama, Panama
                [ 8 ]Hospital Escuela Universitario, Tegucigalpa, Honduras
                [ 9 ]Hôpital Saint Damien, Tabarre, Haiti
                [ 10 ]Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN
                [ 11 ]Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, TN
                Author notes
                Sheena Mukkada, MD, MPH, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, 262 Danny Thomas Pl, Mail Stop 721, Memphis, TN 38105; e-mail: Sheena.Mukkada@ 123456stjude.org .
                Article
                1900329
                10.1200/JGO.19.00329
                7124939
                32216650
                f8a574d5-cc16-44c4-8496-8b439f9d91a2
                © 2020 by American Society of Clinical Oncology

                Creative Commons Attribution Non-Commercial No Derivatives 4.0 License: https://creativecommons.org/licenses/by-nc-nd/4.0/

                History
                : 21 January 2020
                Page count
                Figures: 0, Tables: 2, Equations: 0, References: 40, Pages: 10
                Categories
                [GLLAC], Geographic Location: Latin America and Caribbean
                00, Non-ASCO Guidelines
                00, Pediatric Oncology
                00, Treatment-Related Complications
                Special Articles
                Custom metadata
                v1

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