Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia
Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia
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DOI：
10.1200/jco.20.00591
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发表时间：
2020-09-20
影响因子：
45.3
通讯作者：
Friedman, Debra L.
中科院分区：
文献类型：
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作者：
Esbenshade, Adam J.;Zhao, Zhiguo;Friedman, Debra L.
目的：绝对中性粒细胞计数大于或等于500/ μ L的发热儿童癌症患者的处理尚不清楚。Esbenshade Vanderbilt （EsVan）风险预测模型已被证明可以预测该人群的血流感染（BSI）可能性，本研究旨在前瞻性地验证并在临床实践中实施这些模型。方法前瞻性收集2015年4月至2019年8月在单一地点使用中心静脉导管的发热儿科癌症患者的数据，初步开发模型（EsVan: 2015年至2017年；EsVan2: 2017年10月至2019年），随后将其应用于外观良好的非严重中性粒细胞减少个体的临床管理。建议低BSI风险（< 10%）患者出院时不使用抗生素，中等BSI风险（10% ~ 39.9%）患者出院前给予抗生素治疗，高BSI风险（> 40%）患者入院时使用广谱抗生素治疗。然后收集7天的结果，对EsVan模型进行前瞻性验证并估计c统计量。结果在937例发热性、非重度中性粒细胞减少发作中，低、中、高风险发作的频率分别为88.9%、8.6%和2.3%。BSI发生率为4.2%（937例中有39例）。在危险组中，低危BSI发生率为1.9%(16 / 834)，中度和高危发作的BSI发生率分别为13.6%和54.5%。21.1%的低危发作在发病时和发病后7天给予经验性静脉注射抗生素，72.3%的发作从不需要静脉注射抗生素。没有死亡或临床代偿丧失可归因于抗生素延迟。对于BSI检测，应用于新队列的EsVan和EsVan2模型的c统计量分别为0.802和0.824。结论：EsVan模型的前瞻性、实时临床应用可准确预测BSI风险，并安全减少发热、非严重中性粒细胞减少的儿科癌症患者不必要的抗生素使用。(C)美国临床肿瘤学会2020
PURPOSE Management of febrile pediatric patients with cancer with an absolute neutrophil count of 500/mu L or greater is unclear. The Esbenshade Vanderbilt (EsVan) risk prediction models have been shown to predict bloodstream infection (BSI) likelihood in this population, and this study sought to prospectively validate and implement these models in clinical practice.METHODS Data were prospectively collected on febrile pediatric patients with cancer with a central venous catheter from April 2015 to August 2019 at a single site, at which the models (EsVan: 2015 to 2017; EsVan2: October 2017 to 2019) were initially developed and subsequently implemented for clinical management in well-appearing nonseverely neutropenic individuals. It was recommended that patients with low BSI risk (< 10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (> 40%) be admitted on broad-spectrum antibiotics. Seven-day outcomes were then collected and EsVan models were prospectively validated and C-statistics estimated.RESULTS In 937 febrile, nonsevere neutropenia episodes, frequencies of low-, intermediate-, and high-risk episodes were 88.9%, 8.6%, and 2.3% respectively. BSI incidence was 4.2% (39 of 937). Within risk groups, low-risk BSI incidence was 1.9% (16 of 834) with BSI incidence of 13.6% and 54.5% for intermediate- and high-risk episodes, respectively. Empirical intravenous antibiotics were administered in 21.1% of low-risk episodes at presentation and at 7 days postpresentation, 72.3% of episodes never required intravenous antibiotics. There were no deaths or clinical decompensations attributable to antibiotic delay. For BSI detection, EsVan and EsVan2 models applied to the new cohort achieved C-statistics of 0.802 and 0.824, respectively.CONCLUSION Prospective, real-time clinical utilization of the EsVan models accurately predicts BSI risk and safely reduces unnecessary antibiotic use in febrile, nonseverely neutropenic pediatric patients with cancer. (C) 2020 by American Society of Clinical Oncology