Intervention Review

G-CSF and GM-CSF for treating or preventing neonatal infections

  1. Robert Carr1,*,
  2. Neena Modi2,
  3. Caroline J Doré3

Editorial Group: Cochrane Neonatal Group

Published Online: 21 JUL 2003

Assessed as up-to-date: 27 APR 2003

DOI: 10.1002/14651858.CD003066

How to Cite

Carr R, Modi N, Doré CJ. G-CSF and GM-CSF for treating or preventing neonatal infections. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003066. DOI: 10.1002/14651858.CD003066.

Author Information

  1. 1

    King's College London, Guy's & St Thomas' Hospital, Haematology, London, UK

  2. 2

    Imperial College, London, Division of Paediatrics, Obstetrics and Gynaecology., London, UK

  3. 3

    MRC Clinical Trials Unit, Division Without Portfolio, London, UK

*Robert Carr, Haematology, King's College London, Guy's & St Thomas' Hospital, Guy's Hospital, St Thomas' Street, London, SE1 9RT, UK. robert.carr@gstt.sthames.nhs.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JUL 2003

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

The colony stimulating factors (CSFs), granulocyte-macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF), are naturally occurring cytokines that stimulate the production and antibacterial function of neutrophils and monocytes. Two strategies have been adopted for exploring whether CSFs can provide clinical benefit for preterm infants. The first has investigated their use as a treatment to improve outcome in established systemic infection, especially when complicated by a low neutrophil count. The alternative strategy has been to use CSFs prophylactically, to prevent sepsis prospectively through stimulation of neutrophil production and bactericidal function.

Objectives

To determine the efficacy and safety of the haemopoietic colony stimulating factors (G-CSF or GM-CSF) in newborn infants, when used for:
a) treatment of suspected or proven systemic infection to reduce mortality, or
b) prophylaxis, to prevent systemic infection in infants at high risk of nosocomial infection.
To determine, in subgroup analysis, the influence of pre-existing or high risk of neutropenia on the outcome of therapy.

Search methods

PubMed, EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003) were searched in April 2003 using the keywords: G-CSF, GM-CSF, infant newborn, with and without the limit Clinical Trial. In addition, reference lists of identified RCTs, meta-analyses and personal files were searched.

Selection criteria

The criteria used to select studies for inclusion were:
Design: RCT.
Subjects: Newborn infants in intensive care.
Interventions: G-CSF or GM-CSF given as treatment in conjunction with antibiotics for suspected or microbiologically proven systemic infection. G-CSF or GM-CSF given as prophylaxis with the aim of reducing the incidence of systemic infection.
Outcomes: Treatment studies reporting all cause mortality. Prophylaxis studies reporting subsequent incidence of sepsis and / or mortality.

Data collection and analysis

Relative risks (RR) and risk differences (RD) with 95% confidence intervals (CI) using the fixed effect model are reported. Number needed to treat (NNT) was calculated for the outcomes that showed a statistically significant reduction in RR.

Main results

Seven treatment studies of 257 infants with suspected systemic bacterial infection and three prophylaxis studies comprising 359 neonates are analysed.

Treatment studies: There is no evidence that the addition of G-CSF or GM-CSF to antibiotic therapy in preterm infants with suspected systemic infection reduces immediate all cause mortality. No significant survival advantage was seen at 14 days from the start of therapy [typical RR 0.71 (95% CI 0.38,1.33); typical RD -0.05 (95% CI -0.14, 0.04)]. However all seven of the treatment studies were small, the largest recruiting only 60 infants.
The subgroup analysis of 97 infants from three treatment studies who, in addition to systemic infection, had clinically significant neutropenia (< 1.7 x 109/l) at trial entry, does show a significant reduction in mortality by day 14 [RR 0.34 (95% CI 0.12, 0.92); RD -0.18 (95% CI -0.33, -0.03); NNT 6 (95% CI 3-33)].

Prophylaxis studies have not demonstrated a significant reduction in mortality in neonates receiving GM-CSF [RR 0.59 (95% CI 0.24,1.44); RD -0.03 (95% CI -0.08,0.02)]. The identification of sepsis as the primary outcome of prophylaxis studies has been hampered by inadequately stringent definitions of systemic infection. However, data from one study suggest that prophylactic GM-CSF may provide protection against infection when given to preterm infants who are neutropenic or at high risk of developing postnatal neutropenia.

Authors' conclusions

There is currently insufficient evidence to support the introduction of either G-CSF or GM-CSF into neonatal practice, either as treatment of established systemic infection to reduce resulting mortality, or as prophylaxis to prevent systemic infection in high risk neonates. No toxicity of CSF use was reported in any study included in this review. The limited data suggesting that CSF treatment may reduce mortality when systemic infection is accompanied by severe neutropenia should be investigated further in adequately powered trials which recruit sufficient infants infected with organisms associated with a significant mortality risk.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

G-CSF and GM-CSF for treating or preventing neonatal infections

Infants born before 32 weeks and infants that are small for their gestational age are at high risk of developing infections while in hospital. These infections can cause death, disability (including cerebral palsy) as a result of damage to nervous tissue as well as contributing to chronic lung disease. Infection-related deaths have remained constant for two decades and antibiotic resistance is increasing, emphasising the need for new ways to prevent infection.

The haemopoietic colony stimulating factors (CSFs), granulocyte-macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF) are naturally occurring substances (cytokines) that can increase circulating white blood cells (neutrophils) and their ability to destroy bacteria. Common minor side effects are low grade fever and skeletal pain. The review authors identified seven treatment studies of 257 premature infants with suspected systemic bacterial infection. Adding G-CSF or GM-CSF to antibiotic therapy did not improve survival, overall. It may be, however, that infants who had clinically low neutrophils at the start of treatment did show some reduction in number of deaths by day 14 (taken from three studies). In three studies in which 359 low birthweight or premature neonates were treated preventatively (prophylaxis) no reduction in deaths was evident in those neonates receiving GM-CSF. GM-CSF was well tolerated with no adverse reactions in these small studies.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

使用GCSF和GMCSF治療或預防新生兒感染

血球生長因子 (CSFs) 、顆粒球巨噬細胞血球生長因子 (GMCSF) 和顆粒球生長因子 (GCSF) 是自然生成的細胞激素,可以促進中性球和單核球的生成和抗細菌功能。用兩種搜尋策略來探討CSFs是否能夠給予早產嬰兒臨床上的好處。第一點是在有全身性感染,尤其併有中性球低下時,應用於治療能不能改善預後。另一點是CSFs的預防性應用,藉由刺激中性球生長和殺菌功能,以求預防敗血症的發生。

目標

評估於新生兒利用血球生長因子 (GCSF或GMCSF) 的效果和安全性。用於a) 治療疑似或證實為敗血症來降低死亡率;或b) 用於預防院內感染高風險嬰兒的全身性感染。於次群體分析,已是中性球低下或屬中性球低下高危群對使用CSF治療的影響。

搜尋策略

使用關鍵字:GCSF、GMCSF、新生兒,有或無限定臨床試驗,在2003年4月搜尋PubMed、 EMBASE、MEDLINE和Cochrane Central Register of Controlled Trials。除此之外,搜尋出的隨機控制試驗、整合分析和個人的檔案所列的參考文獻表單,也被加以搜尋。

選擇標準

選擇研究的標準包括:實驗設計:隨機控制試驗;對象:加護照顧的新生兒;處置:對於疑似或證實細菌的全身性感染合併使用GCSF或GMCSF及抗生素,預防性使用GCSF或GMCSF以求降低全身性感染發生率;結果:治療研究報告了所有死亡原因。預防試驗報告了後來敗血症發生率和死亡率的結果。

資料收集與分析

用固定效果模式是計算相對危險 (RR) 和危險差異 (RD) ,採95% 信賴區間 (CI) 。以統計學上明顯降低RR來計算需治療的數目 (NNT) 。

主要結論

7個治療研究,共257個疑有全身細菌感染的嬰兒及3個預防研究,共359個新生兒納入分析。治療研究:沒有證據顯示於疑有全身性感染的早產兒,抗生素治療合併GCSF或GMCSF會減少所有原因立即的死亡。開始治療14天後,沒有明顯生存優勢[typical RR 0.71 (95% CI 0.38,1.33); typical RD −0.05 (95% CI −0.14, 0.04)]。雖然所有7個治療研究,但規模都不大,其中最大規模只有60個嬰兒。次群分析3個治療研究共97個嬰兒,有全身性感染併有臨床明顯中性球低下 (<1.7 x 109/l) ,確實在第14天時有明顯減少死亡率[RR 0.34 (95% CI 0.12, 0.92); RD −0.18 (95% CI −0.33, −0.03); NNT 6 (95% CI 3 – 33)]。預防研究沒有顯示接受GMCSF的新生兒可明顯減少死亡率[RR 0.59 (95% CI 0.24,1.44); RD −0.03 (95% CI −0.08,0.02)]。以敗血症為預防研究的預後結果會被不明確全身性感染定義所限制。然而,從另一研究顯示預防使用GMCSF可以保護有中性球低下或具高危險性發生產後中性球低下的早產兒免於感染。

作者結論

現在沒有足夠證據支持GCSF或GMCSF使用於新生兒,不管是全身性感染的治療以求降低死亡率,或是高危險群的新生兒預防全身性感染。在此回顧分析並沒有任何研究,報告CSF使用發生的毒性。有限的資料顯示,CSF治療可能可以降低全身感染合併嚴重中性球低下的死亡率之說法,應待後續納入更多具高死亡率感染症嬰兒的研究才能成立。

翻譯人

本摘要由馬偕醫院張龍翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

概要尚待完成