Challenges in managing infections among pediatric cancer patients: Suboptimal national essential medicines lists for low and middle income countries.

Infection management for pediatric cancer patients may be compromised in low and middle income countries (LMICs) if key antimicrobials are not included in national essential medicines lists. We screened national essential medicines lists for 81 LMICs, and assessed the frequency and corresponding 95% confidence limits (CL) of countries that included the 15 International Society of Paediatric Oncology-recommended antimicrobial agents. Only 19% (95% CL: 11%, 28%) of countries included all recommended antimicrobials in their national essential medicines lists. The selection of antimicrobial agents for national essential medicines lists in LMICs warrants attention from a pediatric cancer perspective. Pediatr Blood Cancer 2015;62:204-207. © 2014 Wiley Periodicals, Inc.

Mucormycosis Rhinosinusitis at Diagnosis of Acute Lymphoblastic Leukemia: Diagnostics and Management Challenges in a Low-Middle-income Country.

We present the case of an adolescent with mucor rhinosinusitis diagnosed concomitantly with acute lymphoblastic leukemia at a hospital in Tegucigalpa, Honduras. We also discuss the challenges faced in the dual management of hematologic malignancies and invasive fungal disease in a low-middle-income country, such as access to diagnostics, immunosuppressants, imaging, and antifungals. Despite these shortcomings, the patient was successfully treated for both the diseases. Low-middle-income country hospitals can effectively treat invasive fungal diseases by providing adequate diagnostic and support services, which can improve the outcomes of pediatric cancer patients.

Predictors of wait-time for antibiotic initiation and association of wait-time with hospital length of stay and ICU admission among children with cancer at the Southern Philippines Medical Center.

BACKGROUND: Expedited antibiotic administration improves the survival of children with cancer and infection. A 1-hour antibiotic wait-time (AWT) post-hospital arrival is a quality-of-care bench mark in healthcare. However, multiple factors preclude achieving this goal in developing countries. Predictors of AWT and its association with hospital length of stay (LOS) and intensive care unit (ICU) admission at the Southern Philippines Medical Center (SPMC) were identified. PROCEDURES: Health and socioeconomic characteristics of 55 children in 92 admissions who required antibiotics were reviewed;and SPMC care providers about institutional capacity and response to suspected infection were surveyed. RESULTS: The mean total AWT was 3 days and 15 hours. For admissions of established patients, mean total AWT and mean LOS were approximately half that for new patients. Admissions from high-income households waited an average 44% less for antibiotics and were discharged 43% sooner than those from medium-income households. Admissions from residence owner families waited 31% less to receive antibiotics, and total AWT for admissions of patients with no insurance was 32% less than for those with insurance. The likelihood of ICU admission increased 20% with every 1-day increase in total AWT (95% CI: 1.021.42). Only 59% of nurses recognized fever as an emergency. CONCLUSIONS: AWT is complex and multifactorial; it may be reduced by educating parents and care providers about infection and infection control and improving the availability of antibiotics and associated supplies. These interventions will most likely reduce ICU admissions and possibly LOS and increase the survival of pediatric oncology patients at SPMC.

Surveillance of healthcare associated infections in pediatric cancer patients between 2004 and 2009 in a public pediatric hospital in Mexico city, Mexico.

Pediatric oncology and hematology patients are at increased risk of developing healthcare associated infections (HAIs). We conducted a prospective surveillance study on children with cancer admitted to the pediatric hematology and oncology units at a public pediatric hospital in Mexico from January 2004 to December 2009. The incidence of HAIs and groups at greatest risk for HAIs were analyzed. The annual HAI incidence rate and incidence density were calculated. Risk factors such as site of infection, HAI types, and cancer diagnosis were studied. A total of 9420 patients participated, and 409 had HAIs (479 episodes). Annual HAI rates were 3.7 to 5.5 per 100 admissions and the incidence density was 5.75 to 6 HAIs per 1000 inpatient days annually. There were 272 (56.8%) bloodstream infections, 45 (9.4%) pneumonia cases, and 44 (9.2%) skin and soft tissue infections. Children with acute lymphoblastic leukemia had 37.2% and those with acute myeloid leukemia had 16.4% of the HAIs. A total of 11.5% of the HAIs were in children with osteosarcoma. The most common pathogens were Gram-negative bacteria. The HAI-associated mortality rate was 3.7%. Although the overall HAI rate is in line with published reports, the mortality rate was higher, suggesting the incorporation of more aggressive methods to treat infections at our hospital.

Improving waste segregation while reducing costs in a tertiary-care hospital in a lower-middle-income country in Central America.

Healthcare waste (HCW) management and segregation are essential to ensure safety, environmental protection and cost control. Poor HCW management increase risks and costs for healthcare institutions. On-going surveillance and training are important to maintain good HCW practices. Our objectives were to evaluate and improve HCW practices at Hospital Bloom, San Salvador, El Salvador. We studied HCW disposal practices by observing waste containers, re-segregating waste placed in biohazardous waste bags, and administering a seven-itemsknowledge survey before and after training in waste management at Hospital Bloom. The training was based on national and international standards. We followed total biohazardous waste production before and after the training. The hospital staff was knowledgeable about waste segregation practices, but had poor compliance with national policies. Re-segregating waste in biohazardous waste bags showed that 61% of this waste was common waste, suggesting that the staff was possibly unaware of the cost of mis-segregating healthcare waste. After staff training in HCW management, the correct responses increased by 44% and biohazardous waste disposal at the hospital reduced by 48%. Better segregation of biohazardous waste and important savings can be obtained by HCW management education of hospital staff. Hospitals can benefit from maximising the use of available resources by sustaining best practices of HCW, especially those in hospitals in lower-middle-income countries.

Cox-2 inactivates Smad signaling and enhances EMT stimulated by TGF-beta through a PGE2-dependent mechanisms.

Although it is well established that mammary tumorigenesis converts transforming growth factor-beta (TGF-beta) from a tumor suppressor to a tumor promoter, the molecular, cellular and microenvironmental mechanisms underlying the dichotomous nature of TGF-beta in mammary epithelial cells (MECs) remains to be determined definitively. Aberrant upregulation of the inducible cyclooxygenase, Cox-2, occurs frequently in breast cancers and is associated with increasing disease severity and the acquisition of metastasis; however, the impact of Cox-2 expression on normal and malignant MEC response to TGF-beta remains unknown. We show here that TGF-beta induced Cox-2 expression in normal MECs during their acquisition of an epithelial-mesenchymal transition (EMT) phenotype. Moreover, stable Cox-2 expression in normal MECs stimulated their invasion, EMT and anchorage-independent growth and inhibited their activation of Smad2/3 by TGF-beta. Conversely, antagonizing TGF-beta signaling in malignant, metastatic MECs significantly reduced their expression of Cox-2 as well as enhanced their activation of Smad2/3 by TGF-beta. Along these lines, elevated Cox-2 expression elicited prostaglandin E(2) (PGE(2)) production and the autocrine activation of EP receptors, which antagonized Smad2/3 signaling in normal and malignant MECs. Importantly, rendering normal and malignant MECs Cox-2 deficient inhibited their production of PGE(2) and acquisition of an EMT morphology as well as potentiated their nuclear accumulation of Smad2/3 and transcription of plasminogen activator inhibitor-1 and p15 messenger RNA. Collectively, our findings establish Cox-2 as a novel antagonist of Smad2/3 signaling in normal and malignant MECs; they also suggest that chemotherapeutic targeting of Cox-2 may offer new inroads in restoring the tumor-suppressing activities of TGF-beta in malignant, metastatic breast cancers.

Understanding hand hygiene behavior in a pediatric oncology unit in a low- to mid-income country.

BACKGROUND/OBJECTIVE: A qualitative method study identified perceived barriers and motivations for hand hygiene (HH) practice in a pediatric oncology unit in Guatemala. METHODS: Data collection included focus groups with participants grouped by job type. Focus group responses were assessed using content analysis. Participants included nurse supervisors, registered nurses, auxiliary nurses, physicians, and auxiliary and support staff and volunteers (n=55). RESULTS: Themes emerged from participant responses, providing a framework to develop and implement targeted interventions to improve HH. Perceived barriers to HH included the following themes: inconsistent HH supplies, time pressures related to workload, lack of HH training for some healthcare workers and patients' families; negative social reactions after reminding others to practice HH; and cultural traditions shaping patients' families' hygiene. Motivations for HH practice included two themes: patient protection and self-protection. Some of these themes were unique to this culture and clinical setting. Recommendations included a preference for visual aids rather than verbal reminders (e.g. HH promotion signage, demonstrations of HH), and disclosure of compliance rates. CONCLUSIONS: The research team concluded that the main barriers and motivations for HH, including culturally-unique and site-specific factors, were identified and used for subsequent HH compliance improvement such as education. Intervention post focus group concentrated in HH education of healthcare providers using e-learning methodology.

Bloodstream infections and inpatient length of stay among pediatric cancer patients with febrile neutropenia in Mexico City.

We assessed the association between bloodstream infections (BSIs) and inpatient length of stay among pediatric cancer patients with febrile neutropenia in Mexico City. The estimated length of stay for BSIs was 19 days, which corresponded with a 100% (95% confidence limits, 60%-160%) relative increase in the length of stay compared with patients for whom no pathogen was identified. Feasible options for reducing the length of stay should be considered to alleviate patient and resource burden.

The epidemiology and clinical characteristics of respiratory syncytial virus infection in children at a public pediatric referral hospital in Mexico.

OBJECTIVES: The aim of this study was to determine the epidemiological and clinical characteristics of children with respiratory syncytial virus (RSV) treated at a public referral children's hospital in Mexico. METHODS: We reviewed RSV infection in patients aged 0-18 years who were treated at Hospital Infantil from January 2004 to December 2008. RESULTS: During the 5 years, 2797 samples were tested for respiratory viruses; 356 samples were positive for any virus, including 266 (74.7%) positive for RSV. Complete clinical information was available for 205 RSV patients. The mean age was 22 months, and 33.7% of the infections were nosocomially acquired. Hospitalization occurred in 187 children. Of 14 deaths, nine were directly attributed to RSV infection. During the study, RSV infections were seen throughout the year, predominating in the colder months. Of the 205 patients, 79.0% (162/205) had an underlying disease. Congenital heart disease was found in 30.2% (49/162), including three children (33.3%) who died of RSV. Thirty-three patients (16.1%) with RSV required mechanical ventilation. None of the children with RSV received palivizumab or ribavirin. CONCLUSIONS: RSV caused high hospitalization rates and admission to intensive care units, especially among those with underlying illnesses and young infants. The data presented here will be useful for strategies to improve outcomes in children at risk of complications.