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cytokine therapy is recommended for radiation doses ≥3Gy in adults, and >2Gy in
children. Practical limitations, such as limited availability and supply of cytokines, need
to be considered when determining the level of exposure that indicates this treatment.
None of these cytokines is approved for the specific indication of radiation-induced
illness. The long-acting form of G-CSF (pegfilgrastim) is FDA approved as a one-dose
therapy for the management of chemotherapy-induced neutropenia in adults and
adolescents weighing more than 45 kg. It is not approved for younger children and
infants. The other two FDA-approved cytokines are G-CSF (filgrastim) and GM-CSF
(sargramostim). These are administered daily until the absolute neutrophil count reaches
>1,000. Dosages for adults and children are 5 µg/kg/day for G-CSF and 250 µg/m 2 /day
for GM-CSF.
Neutropenia: Antibiotic Therapy
Each institution or agency should follow established guidelines to develop a standardized
plan for the management of febrile, neutropenic patients. Antimicrobials should be used
mainly in radiation victims who develop fever and neutropenia. An empirical regimen of
antibiotics should be selected, based on the degree of neutropenia and on the pattern of
bacterial susceptibility and nosocomial infections in the particular area and institution
(Table 6.8). Broad-spectrum empirical therapy (see below for choices) with high doses of
one or more antibiotics should be initiated at the onset of fever. The antimicrobial
spectrum should include efficacy against gram-negative aerobic organisms, which
account for more than 75% of the isolates causing sepsis. Aerobic and facultative grampositive
bacteria (mostly alpha-hemolytic streptococci) cause sepsis in about 25% of
victims, so coverage for these organisms may also be necessary, especially in institutions
where infection from these organisms is prevalent. Antimicrobials that decrease the
number of strict anaerobes in the gut (e.g., metronidazole) generally should not be given,
because they may promote systemic infection and death from aerobic or facultative
anaerobic bacteria.
If infection is confirmed by cultures, the empirical regimen may require adjustment to
provide appropriate coverage for the specific isolate(s). After the patient becomes
afebrile, the initial regimen should be continued for a minimum of an additional 7 days.
Therapy may need to be continued for at least 21–28 days or until the risk of infection has
declined because of recovery of the immune system. A mass casualty situation may mandate
the use of oral antimicrobials.
The initial antibiotic regimen should be modified when microbiological culture shows
specific bacteria that are resistant to the initial antimicrobials. Modification, if needed,
should also be considered after a thorough evaluation of the history, physical examination
findings, laboratory data, chest radiographs, and epidemiologic information. If resistant
gram-positive infection is evident, vancomycin should be added. If diarrhea is present,
fecal cultures should be examined for enteropathogens (e.g., Salmonella, Shigella,
Campylobacter, and Yersinia).
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