Early discontinuation of intravenous antimicrobial therapy in pediatric oncology patients with febrile neutropenia

Abstract

BackgroundThere are no standard criteria for when to discontinue intravenous antimicrobial therapy (IVAMT) in children with febrile neutropenia (FN), but it is now common to discontinue IVAMT and discharge patients with an absolute neutrophil count (ANC) ≤ 500 /mm3. The purpose of this study was to evaluate the outcome of a large cohort of children with FN who had IVAMT discontinued with an ANC ≤ 500 /mm3MethodsA retrospective chart review was completed of patients in the Northern Alberta Children's Cancer Program with FN and no apparent clinical source of fever from June 1, 1997 to July 1, 2002.ResultsOut of a total of 275 patients, 127 (46%) had at least one episode of FN, with FN occurring in patients with sarcomas more commonly than in those with leukemia/ lymphoma and least in those with other solid tumors. In 59 of 276 episodes of FN (21%) patients had a microbiologically defined infection at admission. Of the 217 remaining episodes, 112 of 199 patients (56%) with known neutrophil counts had IVAMT discontinued before their absolute neutrophil count (ANC) reached 500 /mm3 at the discretion of the clinician. Fever recurred in only two of these patients after discharge, and there were no bacterial infections diagnosed after parenteral antibiotics were discontinued.ConclusionEven without use of standard criteria for early discharge, clinicians appear to be skilled at selecting children with FN who can safely have IVAMT discontinued with an ANC ≤ 500 /mm3.

Early Discharge of Neutropenic Pediatric Oncology Patients Admitted With Fever

“…Similarly, Hodgson‐Viden et al. reported excellent outcomes for 112 children with FN discharged prior to neutrophil recovery at the discretion of the treating physician with no subsequent infections . In a randomized study by Santolaya et al., 36 children had IV antibiotics discontinued after 72 hr regardless of ANC and found similar rates of bacterial infection to the group that continued on antibiotics with no deaths …”

“…As this study is retrospective, the specific reason for not discharging the patient is often not known. Despite our inability to capture this information for this study, there is no question that clinical judgment plays an important role in the selection of neutropenic patients who can be safely discharged …”

“…Admission for febrile neutropenia has decreased mortality in patients with chemotherapy‐induced neutropenia . Most children that require admission for FN do not have an identifiable source for fever, and of the chances of identifying a clinically significant infection are reported to be 12–53% . The current Infectious Diseases Society of America guidelines state that for adult patients with fever and no identified infection, empiric antibiotic therapy should continue until their absolute neutrophil count (ANC) is rising and ≥500 cells/mm 3 .…”

European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia

“…Major factors to consider when choosing empirical therapy for febrile neutropenic patients, based on the literature review (6, 8, 9, 18-24, 26, 31, 35-43, 51, 53, 54 © F e r r a t a S t o r t i F o u n d a t i o n 2 0 1 3 tional studies in children and adults also show that, although the discontinuation of antibiotics is associated with relapse of fever in a few neutropenic patients, there is no increase in mortality, providing the antibacterials are re-started immediately if fever recurs. [63][64][65][66][67][68][69][70][71] These studies included patients with prolonged neutropenia, and, therefore, classically judged to be at high risk of bacterial infection. [63][64][65][67][68][69][70][71][72][73][74][75] Evidence of bone marrow recovery was required before stopping antibiotics in only a minority of these studies.…”

Mise en place de recommandations thérapeutiques pour la prise en charge des neutropénies fébriles chez les enfants atteints de cancer : expérience du RIFHOP

“…. [20][21][22][23][24]. Dans notre étude, nous avons choisi de proposer un relais de l'antibiothérapie par voie orale à H72, malgré la persistance de la neutropénie, en l'absence de fièvre et de documentation bactériologique chez un enfant en bon état général compliant à la prise orale des antibiotiques et pour lequel la PCT était infé-rieure à 0,12 mg/L au moment de la prise en charge de la NF.…”