Paediatrics: Acute care

Acute care

All paediatric oncology treatment centres should have clear local guide-lines for supportive management, which should be referred to for details. This section should not be regarded as a substitute for such guidelines. Fever should be treated as an emergency. Immunocompromised children may succumb to overwhelming sepsis within hours. Greatest risk is as-sociated with the nadir white cell count (typically at around 10 days) for most regimens. In the absence of neutropenia, central venous line infec-tion should be considered, particularly if there are symptoms (e.g. rigors) associated with line flushing.

Febrile neutropenia

Fever (temperature >38°C) with neutrophil count <1.0 × 10⁹/L, leading to increased risk of bacterial infections. Complicates chemotherapy, spinal radiotherapy, bone marrow disease.

Causes

·  Skin or GI bacterial flora.

·  Greatest risk from Gram –ve organisms, including Pseudomonas.

·  Gram-+ve organisms may be associated with central venous catheters.

Examination 

Include inspection of the skin, mouth, IV line sites, surgical sites, and the perianal area.

Investigation

·  FBC and differential count, CRP.

·  Culture of blood, urine, stool, swabs of throat, nose, suspicious skin lesions, or central line exit sites.

·  CXR/AXR if indicated by symptoms or signs.

Treatment

·  Broad spectrum antibiotics should be commenced without delay as infection with Gram –ve bacilli may be fatal within hours.

·  Antibiotic choice will vary by institution and local resistance patterns, but must include adequate cover for Pseudomonas and Gram-+ve organisms. Include anaerobic cover in the presence of abdominal pain, diarrhoea, or mucositis. Appropriate agents may include:

·  Ceftazidime, ciprofloxacin, meropenem, gentamicin, amikacin, piptazobactam (Gram –ve cover).

·  Vancomycin, teicoplanin (Gram +ve organisms, including coagulase-negative staphylococci).

·  Metronidazole, meropenem (anaerobic cover).

Antibiotic choice should be reviewed according to results of cultures.

Infection

Viral infections in immunocompromised patients

·VZV: if in contact and non-immune, give prophylactic aciclovir or zoster immune globulin. Active chickenpox or shingles should be treated aggressively with IV aciclovir.

·HSV: may cause painful oral ulceration; treat early.

Other viruses

·CMV, RSV, and adenovirus may all cause pneumonitis, associated with high morbidity and mortality, especially in BMT patients.

Fungal infections

·Consider in prolonged febrile neutropenia and treat promptly. Mortality remains high, but reduced with newer therapeutic agents.

·Clinical spectrum includes pulmonary aspergillosis, hepatic candidiasis, abscess formation.

·Risk is highest during intensive chemotherapy, such as re-induction for relapsed leukaemia and following BMT.

·Treatment includes fluconazole (limited cover), itraconazole, amphotericin B (liposomal formulation for reduced toxicity), voriconazole, and caspofungin. Prophylaxis is used in high risk treatment regimens.

Pneumocystis pneumonia (PCP)

·Interstitial pneumonitis: associated with prolonged immunosuppression; presents with tachypnoea, dry cough, low oxygen saturation readings.

·Prophylaxis (patients on chemotherapy lasting over 6mths): co-trimoxazole, monthly pentamidine nebulizers, or dapsone.

Treatment: high dose co-trimoxazole, steroids in severe cases.