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 ~  Abstract
 ~ Introduction
 ~  Materials and Me...
 ~ Results
 ~ Discussion
 ~ Conclusion
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  Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 226-229
 

Interleukin-5, interleukin-6, interleukin-8 and tumour necrosis factor-alpha levels obtained within 24-h of admission do not predict high-risk infection in children with febrile neutropenia


1 Department of Immunopathology, Pediatric Hematology Oncology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission07-Mar-2013
Date of Acceptance01-Jun-2013
Date of Web Publication25-Jul-2013

Correspondence Address:
D Bansal
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: PGIMER research grant,, Conflict of Interest: None


DOI: 10.4103/0255-0857.115624

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 ~ Abstract 

Purpose: Biomarkers that can predict the severity of febrile neutropenia (FN) are potential tools for clinical practice. Objective: The objective of this study is to evaluate the reliability of plasma interleukin (IL) levels as indicators of high-risk FN. Materials and Methods: Children with haematological malignancies and FN were enrolled prospectively. A blood sample was obtained within 24-h of admission for estimation of IL-5, IL-6, IL-8 and tumour necrosis factor-alpha (TNF-α) level by the enzyme-linked immunosorbent assay. Patients were stratified into three groups. Group I (low-risk): No focus of infection; Group II: Clinical/radiological focus of infection; Group III: Microbiologically proven infection or FN related mortality. Groups II and III were analysed as high-risk. The cytokines were assessed at three different cut-off levels. Results: A total of 52 episodes of FN in 48 patients were evaluated. The mean age was 6 years (range: 2-13). Primary diagnosis included acute lymphoblastic leukaemia (82%), non-Hodgkin's lymphoma (13%) and acute myeloid leukaemia (5%). Absolute neutrophil count was < 200 cells/μl in half and 200-500 in 23%. Majority were categorised as Group I (69%), followed by Group II (16%) and III (15%). The range of IL-5 was too narrow and similar in the two risk-groups to be of any relevance. The best sensitivity of TNF-α and IL-6 for high-risk group was 78% and 70%, respectively. The highest specificity observed was 35%. The negative predictive value of IL-6, IL-8 and TNF-α exceeded 80%. Conclusion: IL-5, IL-6, IL-8 and TNF-α failed as predictors of clinically localised or microbiologically documented infection in children with chemotherapy induced FN. However, IL-6, IL-8 and TNF-α could be useful in excluding the possibility of high-risk infection.


Keywords: Acute lymphoblastic leukaemia , cancer, C-reactive protein, culture, cytokines, interleukin, tumour necrosis factor


How to cite this article:
Aggarwal R, Bansal D, Bansal F, Nanda N, Ray P, Trehan A, Marwaha R K. Interleukin-5, interleukin-6, interleukin-8 and tumour necrosis factor-alpha levels obtained within 24-h of admission do not predict high-risk infection in children with febrile neutropenia . Indian J Med Microbiol 2013;31:226-9

How to cite this URL:
Aggarwal R, Bansal D, Bansal F, Nanda N, Ray P, Trehan A, Marwaha R K. Interleukin-5, interleukin-6, interleukin-8 and tumour necrosis factor-alpha levels obtained within 24-h of admission do not predict high-risk infection in children with febrile neutropenia . Indian J Med Microbiol [serial online] 2013 [cited 2020 May 30];31:226-9. Available from: http://www.ijmm.org/text.asp?2013/31/3/226/115624



 ~ Introduction Top


Febrile neutropenia (FN) in patients receiving chemotherapy for malignancy is a frequent complication. The standard management is the administration of empirical broad spectrum antibiotics. Timely and dependable identification of low-risk patients will facilitate decision for avoiding antibiotics; thus, reducing cost as well as antibiotic resistance. [1] Cytokines are polypeptides released by activated monocytes and macrophages that mediate a wide variety of biological effects and play an important role in inflammation and immune response. [2] The role of cytokines in risk-stratification and defining prognosis of FN is still evolving. There are varied and heterogeneous studies that have evaluated the role of cytokines in children with FN; results are conflicting. [3],[4],[5] Evidence in the milieu of developing countries is particularly scarce. The aim of this study was to evaluate if plasma levels of interleukin-5 (IL-5), IL-6, IL-8 and tumour necrosis factor-alpha (TNF-α) obtained within 24 h of admission are indicative of clinically or microbiologically defined infection in children with FN.


 ~ Materials and Methods Top


The prospective study was conducted in a paediatric oncology unit over a period of 12 months. Patients with haematological malignancies receiving chemotherapy and admitted with FN were enrolled. Patients who had been initiated on chemotherapy for less than 14 days for a new or relapsed disease were excluded to avoid active disease being a possible confounder in the assessment of cytokines. Neutropenia was defined as an absolute neutrophil count (ANC) of < 500/μl or, <1000/μl with a predicted decline to < 500/μl, within the next 2 days. [6] Fever was defined as a temperature of > 38.3°C once or > 38°C twice, lasting for at least 1 h or measured twice within 12 h. [6] Investigations at admission included a blood count and bacterial culture. Radiological investigations and cultures from other body fluids were obtained as clinically relevant. A total of 2 ml of blood was collected within 24 h of admission for estimation of cytokines. The episodes were stratified into three groups. Group I: No focus of infection; Group II: Clinical/radiological documented focus of infection; Group III: Microbiologically proven infection or FN related mortality. For analysis, Group I patients were considered as 'low-risk' and Group II and III as 'high-risk'. An episode of FN was considered an independent episode in a patient when it was > 4 weeks apart from the previous one, with the patient being clinically well in between.

The samples collected in ethylene diamine tetra acetic acid were centrifuged; plasma was stored at − 20°C for a collective run. The cytokines was measured using commercially available enzyme-linked immunosorbent assay kits (Bender MedSystems GmbH, Austria) according to the manufacturer's instructions. The samples were run in duplicate; mean of two values was reported. Each cytokine was assessed at three different cut-off levels; these cut-offs were selected to cover the range of values obtained. The study was approved by the Institute's Ethics Committee. Informed consent was obtained from parents/guardians.

Statistical analysis

Group comparison was performed using 2-tailed independent sample t-test, Mann-Whitney U or χ2 -test as appropriate. Receiver operating characteristics curves were constructed for deriving sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) for various cut-off levels. All tests were two-tailed and P < 0.05 was taken as significant. Analysis was performed on SPSS version 18.


 ~ Results Top


A total of 52 episodes of FN in 48 patients were evaluated. The mean age was 6 years (range 2-13). Male:Female ratio was 3.2:1. The primary diagnosis in the majority (82%) was acute lymphocytic leukaemia, followed by non-Hodgkin's lymphoma (13%) and acute myeloid leukaemia (5%). The ANC was < 200 cells/μl in 26 (50%) and 200-500 in 12 (23%) episodes. The risk stratification was: Group I: 35 (67%); Group II: 9 (17%) and Group III: 8 (15%) febrile episodes. Majority (35; 67%) of episodes were in low-risk category and 17 (32%) in high-risk. Microbiologically proven infection was observed in 7 (13.4%) patients. Organisms isolated from blood culture included Escherichia coli (2), Enterobacter spp. (2), Klebsiella pneumonia (1) and Staphylococcus aureus (1). Aspergillus was isolated from maxillary sinus in one episode. Four patients died of FN; three of them had a positive culture.

The mean cytokine levels were higher in the high-risk group; however, none was significant. The results are detailed in [Table 1], [Table 2], [Table 3].
Table 1: The mean cytokine levels in the low-and high-risk groups


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Table 2: Significance of IL-8, IL-6 and TNF-α at various cut-off levels in low versus high-risk group


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Table 3: Diagnostic relevance of IL-8, IL-6 and TNF-α for predicting high-risk group


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IL-8

A wide variability was noticed in the plasma levels of IL-8. The mean was 310 pg/ml (range: 0-2000). The significance of IL-8 was derived at various cut-off levels of 15, 150 and 300 pg/ml. A level > 300 pg/ml was more common in the high-risk group (41% vs. 17%), though it failed to reach statistical significance (P = 0.06). The sensitivity and specificity were low; though, the NPV was 88 at a cut-off value of 15 pg/ml.

IL-6

The mean IL-6 level was 69 pg/ml (range: 1-360). The significance was calculated at various cut-offs (10, 50 and 100 pg/ml). A level > 100 pg/ml was more common in high-risk group (41%) as compared with the low-risk (11%) (P = 0.014). The corresponding sensitivity and specificity were however very low. The NPV was 82 at cut-off value of 10 pg/ml.

TNF-α

The mean TNF-α value was 25.6 pg/ml (range: 0-400). The significance was assessed at cut-off level of 5, 10 and 25 pg/ml. It failed to be a predictive of the high-risk group, though the NPV was 88 at cut-off level of 5 as well as 25 pg/ml.

IL-5

The mean IL-5 level was 4.2 pg/ml (range: 1.8-16). The range of IL-5 levels in the two groups was too narrow and similar to be of any predictive value (P = 0.26) (data not shown).


 ~ Discussion Top


Discrimination between serious and inconsequential infections in FN at presentation is often difficult. Although, the paradigm of treating all patients with neutropenia with broad-spectrum antibiotics at the first sign of fever has drastically reduced mortality, currently nearly two-third children are treated without a source of fever being identified. An ideal biomarker should be able to risk stratify FN patients early in the clinical course. [3] Conflicting results have been reported on the clinical utility of cytokine determination in patients with FN. A meta-analysis of biomarkers in predicting adverse outcome in FN in children with cancer was reported recently. [4] 25 studies exploring 14 different biomarkers in 3,585 episodes of FN were scrutinized. The authors concluded that data was limited and firm conclusions could not be reached. IL-6, IL-8 and procalcitonin appeared promising. [4]

IL-5 is produced by T-helper 2 and mast cells. [7] There are limited studies that have investigated its role in FN. Aquino et al., [8] reported IL-5 level > 8 pg/dL to have a sensitivity of 67% and specificity of 96% in predicting bacteremia in 58 episodes of chemotherapy-induced FN in children. Hodge et al., [9] observed significantly higher levels of IL-5 in culture-positive as compared to culture-negative group in a study of 31 paediatric oncology patients (P = 0.047).

There are several single centre studies that have explored the role of IL-6 and IL-8. Abrahamsson et al., [10] reported IL-6 to be a sensitive predictor of bacterial infection in neutropenic as well as non-neutropenic febrile children with malignancy; however, the predictive value was too low. Diepold et al., [11] reported IL-6 to be the best predictor for bacteremia or severe bacterial infection with high sensitivity (90%) and specificity (85%) in 141 febrile episodes in paediatric oncology patients.

IL-8 level has been shown to increase much earlier than C-reactive protein (CRP). [12],[13] Though CRP is widely used as a marker for bacterial infection, it has several disadvantages including delayed increase and low specificity. [14] Akin to our study, Urbonas et al., [15] demonstrated high NPV on day 1 for IL-6 and IL-8 (89% and 82%, respectively) for exclusion of bacteraemia/sepsis in 61 episodes of FN. The authors concluded that IL-6/8 and IL-8 could not reliably predict bacterial infection because of low sensitivity and PPV; however, they could be useful for excluding patients with bacteraemia or clinical sepsis. [15] Their best cut-off levels were higher than in our study. Lehrnbecher et al., [16] evaluated 311 febrile episodes in three paediatric cancer centres. Similar to our study, they found high NPV (≥95) but a low PPV (≤38) for IL-6 and IL-8 for predicting serious infection. [16] In a contrasting study, Miedema et al., [14] reported IL-8 to be a sensitive (92%) marker for the early detection of bacterial infection. Oude Nijhuis et al., [17] reported a successful application of IL-8 along with objective clinical parameters in identification of low-risk patients, allowing antibiotics to be withheld. It is plausible that with a greater number of patients in our study, an IL-8 level > 300 pg/ml could have attained statistical significance for predicting high-risk group. However, the sensitivity (46%) and specificity (26%) for this cut-off was unacceptably low.

Buyukberber et al., [5] determined serum IL-6, IL-8, TNF-alpha, CRP among other markers in 22 patients with various malignancies. IL-8 levels were found to have the most reliable and stable elevation in FN; nevertheless, it was unable to discriminate among risk groups and was a poor predictive factor. [5] Stryjewski et al., [12] demonstrated calcitonin precursors combined with IL-8 (but not IL-6) to be highly sensitive and specific marker of bacterial sepsis in FN. Similar to our results, Persson et al., [18] observed high NPV for IL-6 and IL-8, among other biomarkers. However, the value to predict the bacteraemia was limited due to low sensitivity and PPV. [18]

TNF-α is involved in the regulation of a wide range of biological processes. Similar to our experience, Soker et al., [19] did not find TNF-α to be useful. Abrahamsson et al., [10] reported TNF-α production to be impaired in neutropenic children. In a recent study, Mian et al., [3] investigated the predictive role of 18 biomarkers in the identification of high-risk FN in children with cancers. Except for procalcitonin and high sensitivity CRP, rest 16 markers (including IL-5, IL-6, IL-8 and TNF-α) were not statistically significant as tools to identify high-risk FN events upon initial presentation. [3] Badurdeen et al., [20] did not observe individual cytokine level to provide adequate sensitivity; however, a combinatorial approach using defined cut-off levels increased the predictive value to a clinically relevant level.

A single centre study with relatively small number of subjects and lack of evaluation of procalcitonin are the limitations of this study. The positive points include a prospective study design, targeted cohort of children with haematological malignancies and systematic evaluation of four different biomarkers on day 1 of admission.


 ~ Conclusion Top


IL-5, IL-6, IL-8 and TNF-α had poor sensitivity and specificity for predicting clinically localised or microbiologically documented infection in children with chemotherapy induced FN. However, due to a favourable NPV (>80%), IL-6, IL-8 and TNF-α could be useful in excluding the possibility of high-risk infection. An ideal biomarker that would genuinely facilitate clinical decisions in everyday practical setting is still awaited.

 
 ~ References Top

1.Urbonas V, Eidukaitë A, Tamulienë I. Increased interleukin-10 levels correlate with bacteremia and sepsis in febrile neutropenia pediatric oncology patients. Cytokine 2012;57:313-5.  Back to cited text no. 1
    
2.Tang Y, Liao C, Xu X, Song H, Shi S, Yang S. Th1/Th2 cytokine profiles in G+/G-bacteremia in pediatric hematology/oncology patients. Pediatr Blood Cancer 2012;58:50-4.  Back to cited text no. 2
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3.Mian A, Becton D, Saylors R, James L, Tang X, Bhutta A, et al. Biomarkers for risk stratification of febrile neutropenia among children with malignancy: A pilot study. Pediatr Blood Cancer 2012;59:238-45.  Back to cited text no. 3
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4.Phillips RS, Wade R, Lehrnbecher T, Stewart LA, Sutton AJ. Systematic review and meta-analysis of the value of initial biomarkers in predicting adverse outcome in febrile neutropenic episodes in children and young people with cancer. BMC Med 2012;10:6.  Back to cited text no. 4
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5.Buyukberber N, Buyukberber S, Sevinc A, Camci C. Cytokine concentrations are not predictive of bacteremia in febrile neutropenic patients. Med Oncol 2009;26:55-61.  Back to cited text no. 5
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6.Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730-51.  Back to cited text no. 6
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7.Takatsu K, Nakajima H. IL-5 and eosinophilia. Curr Opin Immunol 2008;20:288-94.  Back to cited text no. 7
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8.Aquino VM, Cost C, Gomez A, Bowers DC, Ramilo O, Ahmad N, et al. Predictive value of interleukin-5 and monocyte chemotactic protein-1 for bacteremia in children with febrile neutropenia. J Pediatr Hematol Oncol 2012;34:e241-5.  Back to cited text no. 8
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9.Hodge G, Osborn M, Hodge S, Nairn J, Tapp H, Kirby M, et al. Rapid simultaneous measurement of multiple cytokines in childhood oncology patients with febrile neutropenia: Increased interleukin (IL)-8 or IL-5 correlates with culture-positive infection. Br J Haematol 2006;132:247-8.  Back to cited text no. 9
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10.Abrahamsson J, Påhlman M, Mellander L. Interleukin 6, but not tumour necrosis factor-alpha, is a good predictor of severe infection in febrile neutropenic and non-neutropenic children with malignancy. Acta Paediatr 1997;86:1059-64.  Back to cited text no. 10
    
11.Diepold M, Noellke P, Duffner U, Kontny U, Berner R. Performance of interleukin-6 and interleukin-8 serum levels in pediatric oncology patients with neutropenia and fever for the assessment of low-risk. BMC Infect Dis 2008;8:28.  Back to cited text no. 11
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12.Stryjewski GR, Nylen ES, Bell MJ, Snider RH, Becker KL, Wu A, et al. Interleukin-6, interleukin-8, and a rapid and sensitive assay for calcitonin precursors for the determination of bacterial sepsis in febrile neutropenic children. Pediatr Crit Care Med 2005;6:129-35.  Back to cited text no. 12
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13.Lindemann A, Tamm I, Tanodi K, Mertelsmann R. Interleukin-8 serum levels for early detection of infectious episodes in neutropenic patients. J Infect Dis 1995;172:610.  Back to cited text no. 13
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14.Miedema KG, de Bont ES, Elferink RF, van Vliet MJ, Nijhuis CS, Kamps WA, et al. The diagnostic value of CRP, IL-8, PCT, and sTREM-1 in the detection of bacterial infections in pediatric oncology patients with febrile neutropenia. Support Care Cancer 2011;19:1593-600.  Back to cited text no. 14
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15.Urbonas V, Eidukaitë A, Tamulienë I. The diagnostic value of interleukin-6 and interleukin-8 for early prediction of bacteremia and sepsis in children with febrile neutropenia and cancer. J Pediatr Hematol Oncol 2012;34:122-7.  Back to cited text no. 15
    
16.Lehrnbecher T, Fleischhack G, Hanisch M, Deinlein F, Simon A, Bernig T, et al. Circulating levels and promoter polymorphisms of interleukins-6 and 8 in pediatric cancer patients with fever and neutropenia. Haematologica 2004;89:234-6.  Back to cited text no. 16
    
17.Oude Nijhuis C, Kamps WA, Daenen SM, Gietema JA, van der Graaf WT, Groen HJ, et al. Feasibility of withholding antibiotics in selected febrile neutropenic cancer patients. J Clin Oncol 2005;23:7437-44.  Back to cited text no. 17
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18.Persson L, Engervall P, Magnuson A, Vikerfors T, Söderquist B, Hansson LO, et al. Use of inflammatory markers for early detection of bacteraemia in patients with febrile neutropenia. Scand J Infect Dis 2004;36:365-71.  Back to cited text no. 18
    
19.Soker M, Colpan L, Ece A, Devecioðlu C, Haspolat K. Serum levels of IL-1 beta, sIL-2R, IL-6, IL-8, and TNF-alpha in febrile children with cancer and neutropenia. Med Oncol 2001;18:51-7.  Back to cited text no. 19
    
20.Badurdeen S, Hodge G, Osborn M, Scott J, St John-Green C, Tapp H, et al. Elevated serum cytokine levels using cytometric bead arrays predict culture-positive infections in childhood oncology patients with febrile neutropenia. J Pediatr Hematol Oncol 2012;34:e36-8.  Back to cited text no. 20
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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