Invasive fungal infection in children with persistent febrile neutropenia.

BACKGROUND AND PURPOSE: Children with persistent febrile neutropenia (fever > 96 hours) refractory to antibacterial therapy carry a high risk of invasive fungal infection (IFI). However, epidemiologic data in such patient populations is lacking in Taiwan. METHODS: A retrospective study was conducted to identify risk factors and outcome of IFI in children with persistent febrile neutropenia (> 96 hours) hospitalized at National Taiwan University Hospital from January 1, 1999 through December 31, 1999. They were categorized into proven, probable, possible, or no IFI according to host, microbiologic and clinical criteria. RESULTS: A total of 29 episodes (35.4%) of IFI occurred in 82 episodes of persistent febrile neutropenia and included 1 proven, 12 probable and 16 possible cases. Pneumonia was most common (69.0%), followed by disseminated infection (17.2%), paranasal sinusitis (6.9%), and hepatosplenic abscess (6.9%). Multivariate analysis revealed 4 risk factors independently associated with IFI: prolonged neutropenia (> 30 days; odds ratio [OR], 10.4; 95% confidence interval [CI], 1.8-60.5), prolonged steroid therapy (OR 2.0, 95% CI 1.0-10.8), allogeneic bone marrow transplantation (OR 5.3, 95% CI 1.0-28.0), and relapsed malignancy (OR 3.5, 95% CI 1.1-11.1). Patients with IFI carried higher in-hospital mortality than those without (51.7% vs 3.8%, p < 0.001). Among those with IFI, delayed antifungal therapy (persistent fever > 7 days) was associated with higher mortality rate than earlier treatment (73.3% vs 28.6%, p = 0.024) and was an independent adverse prognostic factor. CONCLUSION: IFI was common in patients with persistent febrile neutropenia and delayed antifungal therapy was an independent adverse prognostic factor.

Bacteremia in hematological and oncological children with febrile neutropenia: experience in a tertiary medical center in Taiwan.

A retrospective study of bacteremia in children with febrile neutropenia admitted to a medical center in Taiwan from January 1999 to December 1999 was performed. There were 190 episodes of febrile neutropenia during this period and 46 pathogens were isolated from blood specimens in 38 bacteremic episodes (7 mixed infections). Pseudomonas aeruginosa (17.4%), Staphylococcus aureus (10.9%), Klebsiella pneumoniae (10.9%), and Enterobacter cloacae (10.9%) were the most common isolates. Three of the 5 isolates of S. aureus were resistant to methicillin. Twenty-three episodes of bacteremia (four mixed infections) were associated with recent antibiotic use. Of the 23 bacteremic episodes with recent antibiotic use, P. aeruginosa (20%), methicillin-resistant S. aureus (10%), K. pneumoniae (10%), Escherichia coli (10%), and E. cloacae (10%) were isolated most often. Relapsed leukemia (odds ratio 3, 95% confidence interval 1.4-6.5) and recent antibiotic therapy (odds ratio 3.4, 95% confidence interval 1.7-7.7) were the independent risk factors of bacteremia. There were 9 mortality cases in patients with bacteremia, including 4 cases with mixed infections, and 5 cases with P. aeruginosa, E. coli, Klebsiella oxytoca, S. aureus, and Streptococcus mitis, respectively. Broad-spectrum antibiotics were necessary in febrile neutropenic children because of the high percentage of mixed infection.

Mycoplasma pneumoniae encephalitis in childhood.

Mycoplasma pneumoniae is an important etiologic agent of acute childhood encephalitis. We retrospectively reviewed 17 cases of M. pneumoniae encephalitis at the Pediatric Department of the National Taiwan University Hospital from April 1997 through March 2000. These cases were diagnosed as having positive immunoglobulin M antibodies (94%), a minimum 4-fold change of complement-fixation antibody titers (47%), or nested polymerase chain reaction. The ages of these patients ranged from 1.5 to 10.9 years (mean, 5.3 years) with a male-to-female ratio of 8:9. The clinical manifestations included fever (94%), altered consciousness (65%), seizure (41%), personality or behavior changes (29%), meningeal sign (24%), visual hallucination (24%), ataxia (12%), Guillain-Barré syndrome (6%), blurred vision (6%), and aphasia (6%). Respiratory symptoms and signs were found in 76% of the patients. Abnormal electroencephalogram and neuroimage were observed in all cases, while abnormal cerebrospinal fluid examination was noted in about one-third of the patients. Five (29%) patients required intensive care because of intractable seizure or respiratory failure. Fourteen (82%) patients recovered completely, but 3 (18%) had sequelae including epilepsy, hydrocephalus, and global neurologic deficits with brain stem dysfunction. In Taiwan, M. pneumoniae should be considered an etiologic pathogen of acute childhood encephalitis if fever and respiratory symptoms and signs are observed with or without abnormal cerebrospinal fluid findings. Supportive treatment is the basis of management.