
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12341-9
10.1016/j.heliyon.2024.e36310
e36310
Research Article
Early stoppage of empirical antibiotic therapy at clinical improvement in paediatric leukaemia patients with high-risk febrile neutropenia (ESAT-HR-FN study): Study protocol of a single centre investigator initiated randomised open label non-inferiority trial
Kn Santhosh Kumar a
Chellapuram Santhosh Kumar a
Ganguly Shuvadeep ganguly.shuvadeep@gmail.com
b⁎⁎
Pushpam Deepam a
Giri Rupak Kumar a
Bakhshi Sameer sambakh@hotmail.com
a⁎
a Department of Medical Oncology, Dr. Bhimrao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
b Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
⁎ Corresponding author. Department of Medical Oncology, Dr. Bhimrao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences (AIIMS), New Delhi, India. sambakh@hotmail.com
⁎⁎ Corresponding author. ganguly.shuvadeep@gmail.com
13 8 2024
30 8 2024
13 8 2024
10 16 e363104 4 2024
6 8 2024
13 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background and rationale

Febrile neutropenia (FN) is one of the major causes of early mortality among children undergoing induction chemotherapy for haematological malignancies. FN occurs in up to 80 % of the children undergoing intensive chemotherapy and FN specific mortality is as high as 10 %. The management of high-risk FN (HR-FN) is by early initiation of broad-spectrum empirical antibiotic therapy (EAT) which is continued till blood count recovery. Adverse effects of prolonged EAT among children without proven infective focus have questioned the rationale behind the duration of EAT. The non inferiority of early stoppage of EAT in patients with low-risk FN (LR-FN) when afebrile for 48 h, irrespective of marrow recovery, is proven among adults and children. However, there is paucity of data regarding the same in children with HR-FN. This study aims to determine whether early discontinuation of EAT in children with HR-FN without proven infective focus who become afebrile and awaiting marrow recovery, would reduce antibiotic duration and their adverse effects without any negative consequences for patients.

Objective

To compare the rates of recurrent fever in paediatric patients (2–18 years) with HR-FN when EAT is continued till marrow recovery (control group) versus when stopped early at defervescence irrespective of marrow recovery (study group).

Methodology

This is the study protocol of a phase 3, single centre, randomized, open label, non-inferiority clinical trial. The primary outcome is the rate of fever recurrence among patients with HR-FN, when EAT is stopped early irrespective of marrow recovery (study group) and will be compared to the rate of fever recurrence on continuation of EAT till marrow recovery which is defined as an absolute neutrophil count (ANC) ≥ 500/mm3 (control group). Secondary outcomes include the comparison of duration of antibiotic use, mortality rates, hospital re-admission rates, requirement of multiple broad-spectrum antibiotics, therapeutic anti-fungal usage and need for organ support between the study and the control groups. A total of 280 children with acute leukaemia undergoing EAT for grade 3 or severe FN (ANC <500/μL) without clinico-laboratory evidence of infective foci are being randomized in the ratio of 1:1 between the study and the control group after defervescence for 48 h. The patients will be followed up for primary outcome (fever recurrence) till the end of induction period (day 35) or recovery of ANC ≥500/mm3 whichever is earlier.

Expected outcome

ESAT-HR FN study is the first large phase 3 randomised study to assess the impact of early stoppage of EAT irrespective of marrow recovery among a homogenous paediatric cohort of HR-FN in the setting of induction chemotherapy for acute leukaemia. This study will be seminal in addressing the duration of EAT in HR-FN among children without infective foci and if proven to be non-inferior this strategy will help to reduce the adverse effects from prolonged antibiotic use, the emergence of drug resistance, decrease hospital stay length and overall health care costs.
==== Body
pmc1 Introduction

In children with haematological malignancies undergoing induction chemotherapy, the resultant neutropenia and subsequent febrile illness has been the major cause of early mortality. Febrile neutropenia (FN) occurs in around 10%–50 % of patients with solid tumours with rates as high as 80 % with hematologic malignancies receiving one or more chemotherapy cycle(s), with resultant FN specific mortality reaching up to 10 percent [1]. The magnitude of inflammatory response is attenuated among neutropenic patients and first febrile episode may be harbinger of a serious underlying infection. Early initiation of broad-spectrum intravenous antibiotics while awaiting detailed evaluation of aetiology for a febrile episode has been shown to decrease the serious infection related complications and death [2]. Blood stream infection is the most common form of documented aetiology for FN [3,3]. Catheter related coagulase-negative staphylococci (CoNS) are frequently isolated bacteria in the Western countries, whereas multidrug-resistant gram-negative bacteria (MDR-GNB) species predominate in the developing countries. In addition, resistant gram-positive pathogens, such as methicillin resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE), have become more common and are the most prevalent resistant isolates in some centres, accounting for 20 % and more because of absence of antibiotic stewardships [[4], [5], [6]]. Also, tropical organisms and viral aetiologies needs to suspected as a cause for febrile neutropenia other than bacteria when cultures are sterile [[7], [8], [9], [10], [11], [12], [13]]. The aetiology for FN remains unidentified in most of the cases [14]. Empirical antibiotic therapy (EAT) is commonly continued till recovery of neutrophil counts, even with the clinical recovery of patients and no documentation of any infective focus.

Due to uncertainty of aetiology, clinical severity, and potential adverse consequences of EAT among patients with FN, risk stratification at presentation remains the central dogma for treatment of chemotherapy induced FN [15]. Multinational Association for Supportive Care in Cancer score (MASCC), or Clinical Index of Stable Febrile Neutropenia (CISNE) scoring are used as risk stratification scores, which are not optimal for stratifying ultra-high-risk adult patients especially when presented with impending organ failure and MASCC is favoured over CISNE in triaging adult patients with FN in emergency [16]. Studies of risk prediction in children include retrospective and prospective observational cohort studies that vary in inclusion criteria, specific definitions of FN, and exact outcomes measured [17]. The process of deriving prediction rules frequently overestimates their effectiveness in practice and the rules require geographic and temporal validation [18,19]. Supplementary Table S1 summarizes the current risk stratification strategies for FN in children.

Among low-risk FN (LR-FN), outpatient oral antibiotic policy and early discontinuation of antibiotics at clinical improvement before marrow recovery have been proven to be equally efficacious and non-inferior to in-patient and prolonged intravenous antibiotic policy till marrow recovery in both adults and children [13,17,[20], [21], [22], [23], [24], [25], [26]]. Among adult patients with high-risk FN (HR-FN), a large multicentre, open label, non-inferiority randomised controlled trial from Netherlands has already demonstrated that stoppage of antibiotics at defervescence without marrow recovery is feasible [27]. However, there is no robust data in children with HR-FN for early stoppage of EAT. A prospective multi-centre randomised study in children with either HR-FN or LR-FN who tested positive for respiratory viral pathogen, when afebrile on antibiotics at 48 h were randomised between early stoppage versus continuation of antibiotics till marrow recovery and it proved non inferiority of early stoppage strategy [28]. However, persistence of virus after clinical recovery, asymptomatic colonization, and other factors questions the implementation of routine testing for virus prior to early stoppage of antibiotics. In a recently conducted systematic review including studies on both adults and children (3 studies included only children) addressing the question of early stoppage of EAT showed that with a shortened antibiotic course there is no difference in mortality, recurrent fever rate, severe infections and hospitalisation, although studies were heterogenous [29]. Supplementary Table S2 summarizes the available evidence supporting or refuting the strategy of early stoppage of EAT at defervescence for FN [23,27,[30], [31], [32], [33], [34], [35], [36]].

Based on current available evidence, it remains unclear whether early stoppage of EAT is a feasible and non-inferior strategy among children with HR-FN at defervescence without any clinical focus of infection. This study describes the clinical trial protocol of ESAT-HR FN study assessing the non-inferiority of early stoppage of EAT compared to continuation of EAT till marrow recovery. The trial protocol is as per the specifications of the SPIRIT statement 2013 version 1.1 (Supplementary Table S3). [37,38].

2 Methods/design

2.1 Study design

ESAT-HR FN is an investigator initiated single centre open label non inferiority study addressing the effectiveness of early stoppage of empirical antibiotics in children with HR-FN during induction chemotherapy for acute leukaemia. The trial protocol has been approved by the institutional ethics committee at All India Institute of Medical Sciences, New Delhi (IECPG-424/September 27, 2018). The trial was conducted according to Declaration of Helsinki and good clinical practices guidelines. The trial was registered in Clinical Trials Registry of India, CTRI/2018/015994. The study flow has been summarised in Fig. 1. There was no involvement of patient, their families or representatives in the design of the study.Fig. 1 Flow of the study.

Fig. 1

2.2 Objectives

i. Primary Objective

To compare the rates of recurrent fever in children (2–18 years) with high-risk febrile neutropenia (HR-FN) between study and control groups.ii. Secondary Objectives• To compare the duration of antibiotics in children (2–18 years) with HR FN between the control and study groups.

• To compare the mortality rates in children (2–18 years) with HR-FN between the control and study groups.

• To compare the rates hospital re-admission in children (2–18 years) with HR-FN between the control and study groups.

• To compare the requirement of third line antibiotics and therapeutic anti-fungal in children (2–18 years) with HR-FN between the control and study groups.

• To study the role of procalcitonin in de-escalation of antibiotics in children (2–18 years) with HR-FN.

2.3 Study population

This study is being conducted among children of acute leukaemia undergoing induction treatment at the in-patient wards and out-patient clinics of Department of Medical Oncology at the Dr. BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, a central government-funded tertiary care cancer hospital. It caters to a population of over 20 million people and has a catchment area including states of Delhi, Uttar Pradesh, Haryana, Bihar, Rajasthan, Punjab and Madhya Pradesh.

2.4 Inclusion criteria

The participants should fulfil all the inclusion criteria prior to enrolment:• Age above or equal to 2 years and below or equal to 18 years.

• Patients diagnosed with therapy naïve or relapsed Acute myeloid leukaemia (AML) or Acute lymphoblastic leukaemia (ALL) and having febrile neutropenia during induction chemotherapy (Supplementary Table S4).

• Blood cultures taken before or within 24 h of starting antimicrobial treatment.

• Children 2–7 years whose parents/legally authorized representative give written informed consent, children 8–18 years who give assent along with written informed consent by parents/legally authorized representative.

• Clinically infection free and afebrile for 72 h on intravenous antibiotics.

2.5 Exclusion criteria

Participants fulfilling any of the below mentioned criteria are excluded from the study.• Already enrolled in the study during previous febrile neutropenia episode.

• Children positive for Human immune-deficiency (HIV) serology.

• Patients on third line antibiotics as per institutional protocol (Supplementary Table S4)

• Patients who required therapeutic antifungals during screening period.

• Patient who requires any type of organ support during treatment of febrile neutropenia (Inotropic support/Mechanical ventilation/haemodialysis).

• Severe renal function impairment defined as creatinine clearance less than 30 ml/min.

• Clinical foci of infection (Pneumonia/Gastroenteritis including necrotising enterocolitis/Urinary tract infection/Soft tissue infection/Meningitis) as per treating physicians' assessment.

• Radiological foci of infection as reported by consulting radiologist (Xray chest/Computed tomographic scan of chest or abdomen or by ultrasonographic scan of abdomen)

• Microbiologic evidence of infection evaluated as per clinical symptoms (Culture/staining/Polymerase chain reaction-based test(s) positive for infectious organism on body fluids like blood, urine, sputum, or cerebrospinal fluid)

• Patient who had undergone hematopoietic stem cell transplant.

• Patient diagnosed as mixed phenotypic acute leukaemia, acute promyelocytic leukaemia, Blastic plasmacytoid dendritic cell neoplasm or Burkitt's leukaemia.

2.6 Recruitment

All children 2–18 years who develops FN during induction therapy for acute leukaemia are screened universally for ESAT HR-FN trial eligibility. Patients with upfront ALL are treated as per ICiCLE-ALL-14 (Indian Collaborative Childhood Leukaemia group) protocol, while those with relapsed ALL with Medical Research Council UK-ALLR1 protocol or Berlin-Frankfurt-Munster (BFM) 90 protocols on outpatient/daycare basis at our institute [[39], [40], [41]]. Children with upfront AML are treated with AD (Cytosine arabinoside, Daunorubicin) protocol as inpatient or ADE induction (Cytosine arabinoside, Daunorubicin, Etoposide) on outpatient basis. Children with relapsed AML are treated as per ADE induction. Outpatient regimen is proved equally efficacy without increase in adverse events [42,43].

Any child who develops first episode of FN during induction chemotherapy for acute leukaemia, is evaluated for possible aetiology and possible infective foci (aerobic blood cultures within 24 h of fever onset, hemogram, renal and liver function tests, chest radiograph, cerebrospinal fluid analysis if clinical suspicion of meningitis, and urine cultures if symptomatic, ultrasonogram of abdomen-pelvis if clinical neutropenic enterocolitis). EAT is initiated as per institutional protocol on dual antibiotics with at least one anti-pseudomonas agent (Supplementary Table S5). Upfront MRSA-coverage are used only in select cases (Supplementary Table S5). Surveillance cultures for colonization by antibiotic-resistant bacteria are not routinely practised [44]. Children are treated uniformly as an in-patient in case of haemodynamic instability, need for organ support or necessitating prolonged infusion medications (third-line antibiotics, Table S4), otherwise the same intravenous antibiotics are administered on outpatient/daycare basis for patients with stable vitals. These subjects are followed alternate day with complete hemogram along with fever monitoring and antibiotic escalation as per institutional protocol in presence of fever (Supplementary Table S4). Children who becomes afebrile for 72 h on EAT with persistent neutropenia {absolute neutrophil count (ANC) < 500/μL}and without any clinical/radiological foci of infection are screened for ESAT-HR FN study. On fever recurrence, antibiotics were restarted uniformly across both groups as per clinical indication.

During this screening time, children and caregivers are provided written and verbal information about the clinical trial in their own understandable language. Once an eligible subject is screened, consent is taken from caregiver prior to enrolment in the study and randomisation. Signed consent and assents (where applicable) are obtained by designed clinical staff (study nurse) assigned to this responsibility. Informed consent is obtained from the parents of patients or from the authorized surrogates. Assent is obtained in children ≥7 years old.

Recruitment in the study was initially planned over 36 months but got significantly delayed due to coronavirus disease-19 pandemic and is expected to complete in six years of the initiation of the study. The study is currently ongoing at the institute and has completed recruitment of 268 patients (95 %) as of December 2023.

2.7 Randomisation

A permuted stratified block randomisation strategy is followed with variable block size [[4], [5], [6], [7], [8]], stratified for type of leukaemia (AML, ALL and relapsed acute leukaemia), using random sequence generated from Random Lists (www.randomlists.com). Study participants are allocated 1:1 between the two study groups. For maintaining allocation concealment, randomisation is being done by a research officer who is not actively involved in the patient recruitment or recording study outcomes. Once randomized, the clinician/study nurse obtains the treatment allocation for that patient and communicate to treating physician.

2.8 Intervention

For the experimental group (antibiotic stop group), EAT is discontinued when the patient remains afebrile, with resolution of signs, symptoms, and normalization of vital signs for ≥72 h with ANC <500/μL (irrespective of ANC count). For the Control group (Antibiotic continuation group), EAT is discontinued only when the patient is afebrile, with resolution of signs, symptoms, and normalization of vital signs for ≥72 h along with recovery of ANC (defined as ≥ 500/μL). Use of prophylactic antifungals, antivirals, and Pneumocystis carinii pneumonia prophylaxis are allowed as per induction protocols and are continued during study period. No prophylactic gram positive or gram-negative antibiotics are allowed during the study period. Growth factors use {Granulocyte colony stimulating factor (GCSF) or Pegylated-GCSF) is allowed on subject to subject basis at the decision of treating physician. The dose and duration of G-CSF/Peg G-CSF (if used) is noted. Blood product transfusions are allowed throughout the study period to maintain haemoglobin above 7 g/dL and platelet count above 20000/μL during febrile episodes or clinical bleeding, and above 10000/μL otherwise.

2.9 Choice of comparator

The standard of care till date for HR-FN among children is to continue EAT till marrow recovery which is defined as ANC >500/μL in patients who have no clinical or laboratory evidence of bacterial infection [26]. Hence, continuation of EAT till marrow recovery was considered as a comparator group.

2.10 Study endpoint

After randomisation, patients are followed up daily for primary and secondary objectives until day 35 of induction or till recovery of ANC ≥500/μL whichever is earlier. With completion of induction and marrow recovery risk of FN drops significantly till consolidation chemotherapy and consequent neutropenia. As percurrent guidelines antibiotics antibiotics are stopped at marrow recovery and afebrile period of 48 h. Trial patients being randomised at afebrile period and fever recurrence being primary outcome, follow up period till end of induction or marrow recovery is clinically meaningful.

3 Rationale for choice of outcome measurement

EAT is commonly continued till marrow recovery to maintain persistent exposure of antibiotics to clear bacteraemia in a severely neutropenic patient, even without any apparent fever. The recurrence of fever due to stoppage of EAT signifies recrudescence of bacteraemia or antibiotic resistance signifying failure of the strategy. The fever recurrence is the first clinically measurable consequence of antibiotic failure, sepsis and multiorgan dysfunction. Hence the fever recurrence is considered in this study as the primary outcome, which is clinically meaningful and easily measurable parameter. Febrile neutropenia subjects during leukaemia chemotherapy induction have multiple confounding factors for monitoring specific adverse effects from antibiotic regimen like multiagent chemotherapy modified as per toxicity, ongoing febrile illness and overlapping multiple antibiotics Though subclinical or less than grade 3 antibiotic specific adverse effects are not captured as secondary outcome, clinical consequences are monitored and will be analysed.

4 Outcome

The outcomes for this study include:

4.1 Primary outcome

• The rate of fever recurrence in experimental group (early stoppage of EAT irrespective of marrow recovery) compared to control group (continuation of EAT till marrow recovery) in children with HR-FN episodes.

4.2 Secondary outcomes

• The duration of EAT in experimental group (early stoppage of empirical antibiotics irrespective of marrow recovery) compared to control group (continuation of antibiotics till marrow recovery) among children (age 2–18 years) with HR-FN.

• The mortality rates in experimental group (early stoppage of empirical antibiotics irrespective of marrow recovery) compared to control arm (continuation of antibiotics till marrow recovery) among children (2–18 years) with HR-FN.

• The rates of hospital re-admission in experimental group (early stoppage of empirical antibiotics irrespective of marrow recovery) compared to control group (continuation of antibiotics till marrow recovery) among children (age 2–18 years) with HR-FN.

• The requirement of third tier antibiotics (defined as Supplementary Table S4) and therapeutic anti-fungal in experimental group (early stoppage of empirical antibiotics irrespective of marrow recovery) compared to control group (continuation of antibiotics till marrow recovery) among children (2–18 years) with HR-FN.

• To study role of procalcitonin in de-escalation of antibiotics in children (2–18 years) with HR-FN.

5 Follow up

The subjects in either group is clinically followed daily with regular temperature monitoring. (six hourly temperature charts) on outpatient basis (Supplementary Table S6). In case of fever recurrence, antibiotics are re-initiated if randomised to stop group or changed if randomised to continuation group along with taking repeat blood cultures or any other laboratory investigations as per the need of clinical status and patients are managed as per standard of care. After randomisation admission policies are uniform across trial groups which include need for prolonged infusion antibiotics, need for 3 tier antibiotics, organ support etc. Patients admitted in hospital are monitored for fever every 4 h, while for outpatients, patients self-monitor for fever with objective documentation of temperature in a pre-designed patient diary (Supplementary Table S6) along with daily physical or telephonic reinforcement by study team. Adherence to antibiotics and laboratory investigations (complete blood count) as per protocol is ensured by every alternate day physical follow-ups and daily telephonic consultations as per convenience of the patients. The timeline of various assessments from enrolment to follow-up is summarised in SPIRIT timeline as in Table 1. Subjects who have recurrent fever are initiated on EAT as per institutional protocol and also evaluated for fungal and viral aetiologies which are documented.Table 1 Participant timeline for assessment of events (SPIRIT Table).

Table 1	STUDY PERIOD	
Screening	Allocation	Post-allocation	Close-out	
TIMEPOINT**	D-3	D0	D1	D2	D3	D4	D5 …	Day 35 of induction or count recovery (whichever is earlier)	
ENROLMENT:	D1-D35 of induction period for episode of neutropenic fever	When afebrile for 72 h, no clinical foci and ANC<500							
Eligibility screen	XX								
Informed consent		XX
Screening just prior to randomisation							
Hemogram, Renal and liver function tests, Blood cultures (must), Other body fluid cultures, Imaging on individual patient basis	XX								
Randomisation and masked Allocation		X							
INTERVENTIONS	
Experimental Arm: Stoppage of antibiotics			X						
Control Arm: Continuation of antibiotics			X						
ASSESSMENTS	
Fever recurrence			X	X	X	X			
Hemogram, Renal and Liver function tests				X		X			
Use of growth factors			X	X	X	X	X		
Use of blood products									
Intravenous antibiotics used and duration of use			X	X	X	X	X		
Need for hospital admission and days of hospital admission			X	X	X	X	X		
Need for organ support (Oxygen, inotrope requirement)			X	X	X	X	X		
Final outcome								X	

6 Safety

All adverse events reported in the trial have been discussed twice among the departmental faculty not involved in the trial for the assessment of causation by the intervention at an open forum and no death is reported to be caused by the intervention. Any death of subjects recruited after the presentation will be reviewed by the same team and if present will be reported timely to institutional ethics committee. Participants are free to withdraw consents at any point of the study and standard of care will not be compromised for the same. Ancillary and post-trial care would continue for both the arms of the study as per disease specific protocols or institutional standard of care.

7 Statistical considerations

7.1 Sample size

A clinical audit conducted over a period of 2 months at the authors’ institute among children with HR-FN undergoing induction chemotherapy for acute leukaemia, prior to initiation of the study. The fever recurrence rate was found to be 36 % among the patients who were given antibiotics till marrow recovery defined as ANC) ≥500/μL. A local prospective clinical audit was preferred for sample size calculation to get a more accurate reflection of infection burden at the local setting. Considering a non-inferiority margin of 15 %, total 125 patients is needed to recruit in each arm to demonstrate non-inferiority of the experimental strategy, with one sided alpha error of 5 % and 80 % power. The non-inferiority margin of 15 % for primary endpoint of fever recurrence was chosen based on the assumption that it translates into an acceptable increase in proportion of clinically meaningful serious medical complication by 3–5% based on previous prospective studies [36,45]. Accounting for 10 % attrition/loss-to-follow-up, total 280 patients (140/group) were planned to be recruited to address the primary end point of fever recurrence. The recruitment was planned over 3 years, however, in view of slowdown of recruitment due to coronavirus disease-19 pandemic in the intervening years, the accrual is likely to be completed by August 2024.

7.2 Statistical analysis plan

Descriptive statistics will be used to summarize the demographic and clinical characteristics of the subjects. For primary objective, the absolute difference in the rates of fever recurrence between the two groups with two-sided 90 % confidence intervals will be estimated to assess the lower limit of one-sided 95 % CI. Non-inferiority will be claimed if lower limit of one-sided 95 % CI does not exceed 15 %. Secondary objectives will be compared for absolute and relative benefits with 95 % CI. The results of logistic regression will be expressed by odds ratio (OR), 95 % Confidence Interval (CI). Subgroup analysis for stratified groups will be done, although the sample size is not powered for stratified subgroups. Regression models (including but not limited to linear, logistic, or proportional hazards models) will be used for exploratory analyses. All analyses will include every randomized patient and be conducted using the intention-to-treat principle analysing according to randomized treatment regardless of treatment received. Additionally, per-protocol analyses will be carried out for the study population based on actual intervention received.

8 Data processing, auditing, storage and dissemination

Individual case record forms (CRF) containing different items dealing with demographic and clinical characteristics of the subjects are being used. Patients’ hospital records are reviewed and telephonic communication with parents are used for capture of any missing data. Separate files are allocated to each patient to store the trial data. All procedures for the handling and analysis of data are conducted using good computing practices meeting institutional guidelines for the handling and analysis of data for clinical trials. The collected data is anonymized, and confidentiality is maintained by allotting unique trial number to participant and collection or management of data is done with reference to this unique number. Consent forms (with identifying data of patients) and Case record forms are kept in locked compartments at the study site that can exclusively be accessed by authorized personnel only.

A separate external data monitoring committee (DMC) or trial steering committee was not constituted. The principal investigator at the All-India Institute of Medical Sciences, New Delhi, is coordinating the study and be responsible for data acquisition and management and statistical analysis. Data will be presented to senior faculty not involved in the trial in the department at regular intervals, currently it has been presented twice at the time of publication of this protocol. Additionally, the data is open for audit or inspection by the institutional ethics committee. The results of the trial are planned to be disseminated by presentation in national/international conferences as well as by publication in a peer-reviewed journal.

9 Discussion

For microbiologically or clinically documented infection, there is un-equivocal evidence regarding duration of antibiotics for at least 7–10 days [26]. In a child presenting with chemotherapy induced FN, the probability of identifying a causative microorganism ranges only between 10 and 40 % [46]. Most FN patients have unidentified aetiology for FN and are being treated with prolonged duration of empirical broad spectrum of antibiotics till marrow recovery which is arbitrarily defined as ANC ≥500/μL. The cause of fever in these subsets of patients of FN are varied and include viral fever syndromes, hemophagocytic lympho-histiocytosis, drug induced, and malignancy induced fever [47]. Most of these aetiologies are not distinguishable clinically and hence, most of the children end up being treated with prolonged duration of antibiotics. However, prolonged use of broad-spectrum antibiotics in patients with FN has been linked to multiple adverse effects including the increase in incidence of multi-drug resistance (MDR) organisms, Clostridium difficile associated diarrhoea and invasive candidiasis [48,49]. Multi-drug resistance especially carbapenem resistance is associated with 5-fold increase in mortality [[50], [51], [52]]. Prolonged antibiotics also alters anaerobic gut microbiota and increases the risk of induction mortality and graft versus host disease (GVHD) during stem cell transplantation [53,54]. Additionally, this results increased costs of treatment and unnecessary healthcare resource utilization.

Due to absence of level 1 evidence, various guidelines have heterogenous recommendations, largely based on retrospective data and expert consensus. Guidelines from American society of clinical oncology (ASCO) published in 2017, Infectious disease society of America (IDSA), in its update in 2010 and European society of clinical oncology (ESMO) suggests a discontinuation of EAT after the marrow recovery and an afebrile period for 24–48 h in high-risk adult patients [46,55]. In addition, ECIL-4 (European conference on infections in leukaemia −4) recommends early discontinuation of EAT irrespective of risk category/marrow recovery among both adults and children and UK-NICE 2013 guidelines also recommend early discontinuation of EAT among high-risk febrile neutropenic adults irrespective of marrow recovery [56,57].

In contrast to adults, the evidence is sparse in paediatric population. The 2023 updated guidelines on children with FN have raised a knowledge gap in early stoppage of EAT in HR-FN with unknown origin during neutropenia which emphasizes the need for a high-quality RCT [25]. The demonstration of non-inferiority of the strategy of early stoppage of EAT independent of marrow recovery, would decrease prolonged use of antibiotics reducing its adverse consequences.

The ESAT-HR-FN trial addresses the stoppage of EAT in a large homogenous paediatric patient with FN during acute leukaemia induction, a high-risk subset in real world scenario in a randomised fashion. The patients are prospectively followed for fever recurrence, along with prospective record of outcomes which are the advantages of the study. Even though, the study follows stratified randomisation based on type of leukaemia (AML, ALL and relapsed leukaemia), it is not powered for individual subgroups. Additionally, use of biomarkers like detection of bacterial DNA in blood or inflammatory markers may help in identification of cases where strategy of early of EAT is prudent [58,59]. This study does not explore various biomarkers, which limits the potential selection of subgroup which benefits the most from the strategy of early stoppage of antibiotics regardless of marrow recovery in patients with HR-FN [60,61]. Furthermore, adverse effects, specifically due to prolonged antibiotics, are not being prospectively monitored in the trial, and in absence of causality assessment, the difference of adverse effects between the two groups with respect to antibiotic use cannot be ascertained. The results of the trial will be valuable in real-world clinical decision-making regarding stoppage of EAT in high-risk paediatric febrile neutropenia.

Clinical trials registration details

Clinical Trials Registry of India, CTRI/2018/015994; Trial Registration Date: October 10, 2018; Amendment to protocol: None.

Funding

The trial is the investigator-initiated trial and do not receive any specific funding. The infrastructure, logistic and administrative support is provided by All India Institute of Medical Sciences, New Delhi where the study is conducted.

Data availability statement

No data was used for the research described in the article.

Ethics declaration

The trial protocol has been approved by the institutional ethics committee at All India Institute of Medical Sciences, New Delhi (IECPG-424/September 27, 2018). The trial was conducted according to Declaration of Helsinki and good clinical practices guidelines. Written informed consent was taken from parent/primary caregiver of all screened children and assent was taken from all children >7 years of age.

CRediT authorship contribution statement

Santhosh Kumar Kn: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology. Santhosh Kumar Chellapuram: Visualization, Project administration, Methodology, Conceptualization. Shuvadeep Ganguly: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Investigation, Data curation. Deepam Pushpam: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Project administration, Conceptualization. Rupak Kumar Giri: Resources, Project administration, Methodology, Investigation. Sameer Bakhshi: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Funding acquisition, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following are the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Multimedia component 2

Multimedia component 2

Multimedia component 3

Multimedia component 3

Acknowledgements

The authors acknowledge the contributions of Priya Sharma, Riya, Himanshi Sharma, Tripti Dhania and Sakshi Sharma and other members of paediatric oncology team, who help in the screening and follow up of the study participants.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e36310.
==== Refs
References

1 Klastersky J. Management of fever in neutropenic patients with different risks of complications Clin. Infect. Dis. 39 2004 S32 S37 10.1086/383050 15250018
2 Piukovics K. Terhes G. Lázár A. Tímár F. Borbényi Z. Urbán E. Evaluation of bloodstream infections during chemotherapy-induced febrile neutropenia in patients with malignant hematological diseases: single center experience Eur J Microbiol Immunol 5 2015 199 204 10.1556/1886.2015.00021
3 Bos M.M.E.M. Smeets L.S. Dumay I. De Jonge E. Bloodstream infections in patients with or without cancer in a large community hospital Infection 41 2013 949 958 10.1007/s15010-013-0468-1 23645474
4 Reddy R. Pathania S. Kapil A. Bakhshi S. Review of spectrum and sensitivity of bacterial bloodstream isolates in children with malignancy: a retrospective analysis from a single center Indian J. Cancer 51 2014 425 10.4103/0019-509X.175363 26842147
5 Ghosh I. Raina V. Kumar L. Sharma A. Bakhshi S. Thulkar S. Kapil A. Profile of infections and outcome in high-risk febrile neutropenia: experience from a tertiary care cancer center in India Med. Oncol. 29 2012 1354 1360 10.1007/s12032-011-9858-3 21336987
6 Gupta A. Singh M. Singh H. Kumar L. Sharma A. Bakhshi S. Raina V. Thulkar S. Infections in acute myeloid leukemia: an analysis of 382 febrile episodes Med. Oncol. 27 2010 1037 1045 10.1007/s12032-009-9330-9 19830601
7 Ghosh I. Bakhshi S. Faizi N.A. Broor S. Fatality in febrile neutropenia due to H1N1 influenza: an alert for pediatric oncologists Pediatr. Blood Cancer 55 2010 1243 1244 10.1002/pbc.22582 20979182
8 Bakhshi S. Acute encephalopathy with parvovirus B19 infection in sickle cell disease Arch. Dis. Child. 87 2002 541 542 10.1136/adc.87.6.541 12456562
9 Bahl A. Bakhshi S. Dengue fever in patients with pediatric malignancy on chemotherapy: a concern in tropical countries Pediatr. Blood Cancer 57 2011 1249 1250 10.1002/pbc.23229 21681938
10 Malik P.S. Broor S. Bakhshi S. H1N1 infection in children with hematological malignancies Indian Pediatr. 48 2011 971 973 22253155
11 Pani C.K. Mohapatra S. Samantaray J.C. Bakhshi S. Visceral leishmaniasis as a cause of persistent fever in pediatric hodgkin lymphoma Pediatr. Infect. Dis. J. 30 2011 630 631 10.1097/INF.0b013e31821dc991
12 Radhakrishnan V. Bhatia R. Panda G.S. Bakhshi S. Acanthamebic meningoencephalitis presenting as personality change Pediatr. Infect. Dis. J. 28 2009 555 10.1097/INF.0b013e31819f3d29
13 Gupta D. Panda G.S. Bakhshi S. Successful treatment of acanthamoeba meningoencephalitis during induction therapy of childhood acute lymphoblastic leukemia Pediatr. Blood Cancer 50 2008 1292 1293 10.1002/pbc.21477 18253958
14 Wood A.J.J. Pizzo P.A. Management of fever in patients with cancer and treatment-induced neutropenia N. Engl. J. Med. 328 1993 1323 1332 10.1056/NEJM199305063281808 8469254
15 Al-Tawfiq J.A. Hinedi K. Khairallah H. Saadeh B. Abbasi S. Noureen M. Raza S. Alkhatti A. Epidemiology and source of infection in patients with febrile neutropenia: a ten-year longitudinal study J Infect Public Health 12 2019 364 366 10.1016/j.jiph.2018.12.006 30594483
16 Wijeratne D.T. Wright K. Gyawali B. Risk-stratifying treatment strategies for febrile neutropenia—tools, tools everywhere, and not a single one that works? JCO Oncol Pract 17 2021 651 654 10.1200/OP.21.00148 33914611
17 Lehrnbecher T. Robinson P.D. Ammann R.A. Fisher B. Patel P. Phillips R. Beauchemin M.P. Carlesse F. Castagnola E. Davis B.L. Guideline for the management of fever and neutropenia in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2023 update J. Clin. Oncol. 41 2023 1774 1785 10.1200/JCO.22.02224 36689694
18 Alexander S.W. Wade K.C. Hibberd P.L. Parsons S.K. Evaluation of risk prediction criteria for episodes of febrile neutropenia in children with cancer J. Pediatr. Hematol. Oncol. 24 2002 38 42 10.1097/00043426-200201000-00011 11902738
19 Dommett R. Geary J. Freeman S. Hartley J. Sharland M. Davidson A. Tulloh R. Taj M. Stoneham S. Chisholm J.C. Successful introduction and audit of a step-down oral antibiotic strategy for low risk paediatric febrile neutropaenia in a UK, multicentre, shared care setting Eur. J. Cancer 45 2009 2843 2849 10.1016/j.ejca.2009.06.003 19616427
20 Freifeld A. Marchigiani D. Walsh T. Chanock S. Lewis L. Hiemenz J. Hiemenz S. Hicks J.E. Gill V. Steinberg S.M. A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy N. Engl. J. Med. 341 1999 305 311 10.1056/NEJM199907293410501 10423464
21 Hidalgo M. Hornedo J. Lumbreras C. Trigo J.M. Colomer R. Perea S. Gómez C. Ruiz A. García-Carbonero R. Cortés-Funes H. Outpatient therapy with oral ofloxacin for patients with low risk neutropenia and fever: a prospective, randomized clinical trial Cancer 85 1999 213 219 9921995
22 Innes H.E. Smith D.B. O'Reilly S.M. Clark P.I. Kelly V. Marshall E. Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study Br. J. Cancer 89 2003 43 49 10.1038/sj.bjc.6600993 12838298
23 Kumar A. Biswas B. Chopra A. Kapil A. Vishnubhatla S. Bakhshi S. Early discontinuation versus continuation of antimicrobial therapy in low risk pediatric cancer patients with febrile neutropenia, before recovery of counts: a randomized controlled trial (dalfen study) Indian J. Pediatr. 88 2021 240 245 10.1007/s12098-020-03377-x 32537711
24 Nahid P. Dorman S.E. Alipanah N. Barry P.M. Brozek J.L. Cattamanchi A. Chaisson L.H. Chaisson R.E. Daley C.L. Grzemska M. Official American thoracic society/centers for disease control and prevention/infectious diseases society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis Clin. Infect. Dis. 63 2016 e147 e195 10.1093/cid/ciw376 27516382
25 Lehrnbecher T. Robinson P. Fisher B. Alexander S. Ammann R.A. Beauchemin M. Carlesse F. Groll A.H. Haeusler G.M. Santolaya M. Guideline for the management of fever and neutropenia in children with cancer and hematopoietic stem-cell transplantation recipients: 2017 update J. Clin. Oncol. 35 2017 2082 2094 10.1200/JCO.2016.71.7017 28459614
26 Lehrnbecher T. Robinson P.D. Ammann R.A. Fisher B. Patel P. Phillips R. Beauchemin M.P. Carlesse F. Castagnola E. Davis B.L. Guideline for the management of fever and neutropenia in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2023 update J. Clin. Oncol. 41 2023 1774 1785 10.1200/JCO.22.02224 36689694
27 De Jonge N.A. Sikkens J.J. Zweegman S. Beeker A. Ypma P. Herbers A.H. Vasmel W. De Kreuk A. Coenen J.L.L.M. Lissenberg-Witte B. Short versus extended treatment with a carbapenem in patients with high-risk fever of unknown origin during neutropenia: a non-inferiority, open-label, multicentre, randomised trial Lancet Haematol 9 2022 e563 e572 10.1016/S2352-3026(22)00145-4 35691326
28 Santolaya M.E. Alvarez A.M. Becker A. Cofré J. Enríquez N. O'Ryan M. Payá E. Pilorget J. Salgado C. Tordecilla J. Prospective, multicenter evaluation of risk factors associated with invasive bacterial infection in children with cancer, neutropenia, and fever J. Clin. Oncol. 19 2001 3415 3421 10.1200/JCO.2001.19.14.3415 11454890
29 Ishikawa K. Masaki T. Kawai F. Ota E. Mori N. Systematic review of the short-term versus long-term duration of antibiotic management for neutropenic fever in patients with cancer Cancers 15 2023 1611 10.3390/cancers15051611 36900403
30 Rodriguez V. Burgess M. Bodey G.P. Management of fever of unknown origin in patients with neoplasms and neutropenia Cancer 32 1973 1007 1012 10.1002/1097-0142(197310)32:4<1007::AID-CNCR2820320437>3.0.CO;2-M 4751910
31 Pizzo P.A. Robichaud K.J. Gill F.A. Witebsky F.G. Levine A.S. Deisseroth A.B. Glaubiger D.L. MacLowry J.D. Magrath I.T. Poplack D.G. Duration of empiric antibiotic therapy in granulocytopenic patients with cancer Am. J. Med. 67 1979 194 200 10.1016/0002-9343(79)90390-5 380336
32 Pizzo P.A. Robichaud K.J. Gill F.A. Witebsky F.G. Empiric antibiotic and antifungal therapy for cancer patients with prolonged fever and granulocytopenia Am. J. Med. 72 1982 101 111 10.1016/0002-9343(82)90594-0 7058815
33 Santolaya M.E. Villarroel M. Avendano L.F. Cofre J. Discontinuation of antimicrobial therapy for febrile, neutropenic children with cancer: a prospective study Clin. Infect. Dis. 25 1997 92 97 10.1086/514500 9243041
34 Klaassen R.J. Allen U. Doyle J.J. Randomized placebo-controlled trial of oral antibiotics in pediatric oncology patients at low-risk with fever and neutropenia J. Pediatr. Hematol. Oncol. 22 2000 405 411 10.1097/00043426-200009000-00004 11037850
35 Santolaya M.E. Alvarez A.M. Acuña M. Avilés C.L. Salgado C. Tordecilla J. Varas M. Venegas M. Villarroel M. Zubieta M. Efficacy and safety of withholding antimicrobial treatment in children with cancer, fever and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial Clin. Microbiol. Infect. 23 2017 173 178 10.1016/j.cmi.2016.11.001 27856269
36 Aguilar-Guisado M. Espigado I. Martín-Peña A. Gudiol C. Royo-Cebrecos C. Falantes J. Vázquez-López L. Montero M.I. Rosso-Fernández C. De La Luz Martino M. Optimisation of empirical antimicrobial therapy in patients with haematological malignancies and febrile neutropenia (How Long study): an open-label, randomised, controlled phase 4 trial Lancet Haematol 4 2017 e573 e583 10.1016/S2352-3026(17)30211-9 29153975
37 Chan A.-W. Tetzlaff J.M. Altman D.G. Laupacis A. Gøtzsche P.C. Krleža-Jerić K. Hróbjartsson A. Mann H. Dickersin K. Berlin J.A. SPIRIT 2013 statement: defining standard protocol items for clinical trials Ann. Intern. Med. 158 2013 200 10.7326/0003-4819-158-3-201302050-00583 23295957
38 Chan A.-W. Tetzlaff J.M. Gotzsche P.C. Altman D.G. Mann H. Berlin J.A. Dickersin K. Hrobjartsson A. Schulz K.F. Parulekar W.R. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials BMJ 346 2013 e7586 10.1136/bmj.e7586
39 Das N. Banavali S. Bakhshi S. Trehan A. Radhakrishnan V. Seth R. Arora B. Narula G. Sinha S. Roy P. Protocol for ICiCLe-ALL-14 (InPOG-ALL-15-01): a prospective, risk stratified, randomised, multicentre, open label, controlled therapeutic trial for newly diagnosed childhood acute lymphoblastic leukaemia in India Trials 23 2022 102 10.1186/s13063-022-06033-1 35101099
40 Tallen G. Ratei R. Mann G. Kaspers G. Niggli F. Karachunsky A. Ebell W. Escherich G. Schrappe M. Klingebiel T. Long-term outcome in children with relapsed acute lymphoblastic leukemia after time-point and site-of-relapse stratification and intensified short-course multidrug chemotherapy: results of trial ALL-REZ BFM 90 J. Clin. Oncol. 28 2010 2339 2347 10.1200/JCO.2009.25.1983 20385996
41 Parker C. Waters R. Leighton C. Hancock J. Sutton R. Moorman A.V. Ancliff P. Morgan M. Masurekar A. Goulden N. Effect of mitoxantrone on outcome of children with first relapse of acute lymphoblastic leukaemia (ALL R3): an open-label randomised trial Lancet 376 2010 2009 2017 10.1016/S0140-6736(10)62002-8 21131038
42 Rubnitz J.E. Kaspers G.J.L. How I treat pediatric acute myeloid leukemia Blood 138 2021 1009 1018 10.1182/blood.2021011694 34115839
43 Garg A. Ganguly S. Vishnubhatla S. Chopra A. Bakhshi S. Outpatient ADE (cytarabine, daunorubicin, and etoposide) is feasible and effective for the first relapse of pediatric acute myeloid leukemia: a prospective, phase II study Pediatr. Blood Cancer 67 2020 e28404 10.1002/pbc.28404
44 Jadhav N. Mandal J. Kayal S. Pattnaik J. Madasamy P. Singh J. Dubashi B. Surveillance stool culture and its association with microbiologically documented infection during febrile neutropenia in patients with acute leukemia (AL) undergoing induction chemotherapy Indian J Hematol Blood Transfus Off J Indian Soc Hematol Blood Transfus 37 2021 543 548 10.1007/s12288-020-01377-7
45 Schauwvlieghe A. Dunbar A. Storme E. Vlak A. Aerts R. Maertens J. Sciot B. Van Der Wel T. Papageorgiou G. Moors I. Stopping antibiotic therapy after 72 h in patients with febrile neutropenia following intensive chemotherapy for AML/MDS (safe study): a retrospective comparative cohort study EClinicalMedicine 35 2021 100855 10.1016/j.eclinm.2021.100855
46 Freifeld A.G. Bow E.J. Sepkowitz K.A. Boeckh M.J. Ito J.I. Mullen C.A. Raad I.I. Rolston K.V. Young J.-A.H. Wingard J.R. Executive summary: clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of America Clin. Infect. Dis. 52 2011 427 431 10.1093/cid/ciq147 21205990
47 Joudeh N. Sawafta E. Abu Taha A. HamedAllah M. Amer R. Odeh R.Y. Salameh H. Sabateen A. Aiesh B.M. Zyoud S.H. Epidemiology and source of infection in cancer patients with febrile neutropenia: an experience from a developing country BMC Infect. Dis. 23 2023 106 10.1186/s12879-023-08058-6 36814229
48 Ohmagari N. Hanna H. Graviss L. Hackett B. Perego C. Gonzalez V. Dvorak T. Hogan H. Hachem R. Rolston K. Risk factors for infections with multidrug‐resistant Pseudomonas aeruginosa in patients with cancer Cancer 104 2005 205 212 10.1002/cncr.21115 15880433
49 Singh N. Trends in the epidemiology of opportunistic fungal infections: predisposing factors and the impact of antimicrobial use practices Clin. Infect. Dis. 33 2001 1692 1696 10.1086/323895 11641825
50 Babiker A. Clarke L.G. Saul M. Gealey J.A. Clancy C.J. Nguyen M.H. Shields R.K. Changing epidemiology and decreased mortality associated with carbapenem-resistant gram-negative bacteria, 2000–2017 Clin. Infect. Dis. 73 2021 e4521 e4530 10.1093/cid/ciaa1464 32990319
51 Kumar A. Mohapatra S. Bakhshi S. Mahapatra M. Sreenivas V. Das B. Sood S. Kapil A. Rectal carriage of carbapenem-resistant enterobacteriaceae: a menace to highly vulnerable patients J. Global Infect. Dis. 10 2018 218 10.4103/jgid.jgid_101_17
52 Kumar A. Mohapatra S. Bir R. Tyagi S. Bakhshi S. Mahapatra M. Gautam H. Sood S. Das B.K. Kapil A. Intestinal colonization due to carbapenem-resistant enterobacteriaceae among hematological malignancy patients in India: prevalence and molecular charecterisation Indian J Hematol Blood Transfus 38 2022 1 7 10.1007/s12288-021-01415-y 35125706
53 Tanaka J.S. Young R.R. Heston S.M. Jenkins K. Spees L.P. Sung A.D. Corbet K. Thompson J.C. Bohannon L. Martin P.L. Anaerobic antibiotics and the risk of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation Biol. Blood Marrow Transplant. 26 2020 2053 2060 10.1016/j.bbmt.2020.07.011 32682948
54 Hayase E. Hayase T. Jamal M.A. Miyama T. Chang C.-C. Ortega M.R. Ahmed S.S. Karmouch J.L. Sanchez C.A. Brown A.N. Mucus-degrading Bacteroides link carbapenems to aggravated graft-versus-host disease Cell 185 2022 3705 3719.e14 10.1016/j.cell.2022.09.007 36179667
55 Klastersky J. De Naurois J. Rolston K. Rapoport B. Maschmeyer G. Aapro M. Herrstedt J. Management of febrile neutropaenia: ESMO clinical practice guidelines Ann. Oncol. 27 2016 v111 v118 10.1093/annonc/mdw325 27664247
56 National Collaborating Centre for Cancer (UK) Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients 2012 National Institute for Health and Clinical Excellence (NICE) London http://www.ncbi.nlm.nih.gov/books/NBK299128/
57 Groll A.H. Castagnola E. Cesaro S. Dalle J.-H. Engelhard D. Hope W. Roilides E. Styczynski J. Warris A. Lehrnbecher T. Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or allogeneic haemopoietic stem-cell transplantation Lancet Oncol. 15 2014 e327 e340 10.1016/S1470-2045(14)70017-8 24988936
58 Chen S.C.-A. Kontoyiannis D.P. New molecular and surrogate biomarker-based tests in the diagnosis of bacterial and fungal infection in febrile neutropenic patients Curr. Opin. Infect. Dis. 23 2010 567 577 10.1097/QCO.0b013e32833ef7d1 20827189
59 Teranishi H. Ohzono N. Inamura N. Kato A. Wakabayashi T. Akaike H. Terada K. Ouchi K. Detection of bacteria and fungi in blood of patients with febrile neutropenia by real-time PCR with universal primers and probes J. Infect. Chemother. 21 2015 189 193 10.1016/j.jiac.2014.11.008 25497674
60 Arif T. Phillips R.S. Updated systematic review and meta‐analysis of the predictive value of serum biomarkers in the assessment and management of fever during neutropenia in children with cancer Pediatr. Blood Cancer 66 2019 e27887 10.1002/pbc.27887
61 Van Der Velden F.J.S. Gennery A.R. Emonts M. Biomarkers for diagnosing febrile illness in immunocompromised children: a systematic review of the literature Front Pediatr 10 2022 828569 10.3389/fped.2022.828569
