Management of infections in children with cancer

Abstract

Infectious complications remain a frequent cause of morbidity and mortality in children with cancer, especially in those who are granulocytopenic. Physicians caring for these children must approach each new febrile episode as if it were life threatening. Questions concerning the present illness must be comprehensive. The physical examination should be done in a compulsive manner because the more obvious signs of inflammation are often absent because of granulocytopenia. Immediate initiation of broad-spectrum intravenous antibiotic coverage is required once the appropriate specimens for diagnostic microbiology studies have been obtained. Because these patients may exhibit either dramatic or, more often, only subtle clinical findings, they must be monitored closely and have a complete physical examination at least daily. The laboratory studies frequently determine the etiology of the fever. Therapy can then be modified, based upon the particular pathogen isolated or the type of infection identified. Because bacterial infections are responsible for most infectious febrile episodes in the granulocytopenic child with cancer, appropriate antibiotic therapy usually is curative. However, some patients remain febrile and granulocytopenic without explanation. These patients frequently have a fungal infection and respond to amphotericin B therapy. Our present armamentarium of antimicrobial agents against the common pathogens encountered in cancer patients, except for cytomegalovirus, is adequate. Future advances in therapy of infections in children with cancer will probably be in the area of immunotherapy. This would include both passive administration of products to strengthen a debilitated immune system, together with active immunization with the aim to prevent infectious complications. Prevention of infection in the cancer population may be one of the keys to producing longer remissions and prolonged overall survival, by enabling pediatric oncologists to administer more intensive induction chemotherapy.