Home-based care of low-risk febrile neutropenia in children—an implementation study in a tertiary paediatric hospital

Haeusler, Gabrielle M; Gaynor, Lynda; Teh, Benjamin W; Babl, Franz E; Orme, Lisa; Segal, Ahuva; Méchinaud, Françoise; Bryant, Penelope A; Phillips, Bob; Lourenço, Richard De Abreu; Slavin, Monica A; Thursky, Karin

doi:10.1007/s00520-020-05654-z

Cited by 22 publications

(50 citation statements)

References 31 publications

(43 reference statements)

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“…73 An implementation study from Australia similarly showed a significant reduction in hospital length (from 4.0 to 1.5 days) with low readmission rates (13%) and no adverse outcomes in patients managed on a formal lowrisk FN program. 78 This program is being scaled nationwide and has been adapted for use in the UK. Beyond safety, home-based FN care has been shown to improve quality of life, and reduce healthcare costs, which have been estimated at between US $5600 and $11,700 per episode of FN, depending on the regimes used for comparison and the country in which the research was performed.…”

Section: Duration Of Treatmentmentioning

confidence: 99%

Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children

Morgan¹,

Phillips²,

Haeusler³

et al. 2021

IDR

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Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating deescalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.

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Section: Duration Of Treatmentmentioning

confidence: 99%

Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children

Morgan¹,

Phillips²,

Haeusler³

et al. 2021

IDR

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“…Implementation of a national paediatric low‐risk FN programme in parallel with the COVID‐19 pandemic has opened the door to new models of care and increased clinician and patient acceptance for home‐based treatment and remote patient assessments. We have identified a number of changes made to the general management of children with cancer across Australia in response to the pandemic that align with the model of home‐based FN care 4,10 . In particular, the increased availability and acceptance of telehealth was acknowledged as a positive change by health‐care workers and parents in our study.…”

Section: Discussionmentioning

confidence: 88%

“…Results of randomised controlled trials also show no increased risk of adverse outcomes in low‐risk patients treated at home on oral or intravenous antibiotics as compared to standard inpatient management 2 . To optimise safety, the low‐risk programme incorporates a validated risk stratification tool and additional safety‐net criteria including mandatory periods of in‐hospital observation and clear directives for medical review and readmission 4,6,20 . While apparent to most clinicians in this survey, the presence of these safety nets need to be better addressed in patient facing information.…”

Section: Discussionmentioning

confidence: 96%

Managing low‐risk febrile neutropenia in children in the time of COVID‐19: What matters to parents and clinicians

Haeusler

Lourenço

Bakos³

et al. 2021

J Paediatrics Child Health

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Aim The Australian ‘There is no place like home’ project is implementing a paediatric low‐risk febrile neutropenia (FN) programme across eight paediatric hospitals. We sought to identify the impact of the coronavirus disease 2019 (COVID‐19) pandemic on programme implementation. Methods Paediatric oncology, infectious diseases and emergency medicine health‐care workers and parent/carers were surveyed to explore the impact of the COVID‐19 pandemic on home‐based FN care. Online surveys were distributed nationally to health‐care workers involved in care of children with FN and to parents or carers of children with cancer. Results Surveys were completed by 78 health‐care workers and 32 parents/carers. Overall, 95% of health‐care workers had confidence in the safety of home‐based FN care, with 35% reporting changes at their own hospitals in response to the pandemic that made them more comfortable with this model. Compared to pre‐pandemic, >50% of parent/carers were now more worried about attending the hospital with their child and >80% were interested in receiving home‐based FN care. Among both groups, increased telehealth access and acceptance of home‐based care, improved patient quality of life and reduced risk of nosocomial infection were identified as programme enablers, while re‐direction of resources due to COVID‐19 and challenges in implementing change during a crisis were potential barriers. Conclusion There is strong clinician and parent/carer support for home‐based management of low‐risk FN across Australia. Changes made to the delivery of cancer care in response to the pandemic have generally increased acceptance for home‐based treatments and opportunities exist to leverage these to refine the low‐risk FN programme.

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“…These patients are potentially eligible for reduced intensity FN treatment including home-based care and oral antibiotics. Using a structured FN pathway incorporating safety-nets, risk-stratification has been shown to be safe and significantly reduce hospital length of stay, antibiotic exposure and costs of care and improve quality of life ( 6 ). While our study has found that biomarker combinations may be more accurate than existing CDRs and identify a larger pool of low risk patients, further studies in addition to validation, are required to explore feasibility and cost of this approach.…”

Section: Discussionmentioning

confidence: 99%

“…Early de-escalation of standard inpatient care and cessation of intravenous antibiotics in patients identified as low-risk has been shown to reduce antibiotic exposure and hospital length of stay and improvement in quality of life (4)(5)(6). Ensuring these management pathways have the greatest impact without compromising patient safety, relies on the early (<24 h) and accurate identification of children with low-risk FN (7).…”

Section: Introductionmentioning

confidence: 99%

Procalcitonin and Interleukin-10 May Assist in Early Prediction of Bacteraemia in Children With Cancer and Febrile Neutropenia

et al. 2021

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ObjectivesFebrile neutropenia (FN) causes treatment disruption and unplanned hospitalization in children with cancer. Serum biomarkers are infrequently used to stratify these patients into high or low risk for serious infection. This study investigated plasma abundance of cytokines in children with FN and their ability to predict bacteraemia.MethodsThirty-three plasma cytokines, C-reactive protein (CRP) and procalcitonin (PCT) were measured using ELISA assays in samples taken at FN presentation (n = 79) and within 8–24 h (Day 2; n = 31). Optimal thresholds for prediction of bacteraemia were identified and the predictive ability of biomarkers in addition to routinely available clinical variables was assessed.ResultsThe median age of included FN episodes was 6.0 years and eight (10%) had a bacteraemia. On presentation, elevated PCT, IL-10 and Mip1-beta were significantly associated with bacteraemia, while CRP, IL-6 and IL-8 were not. The combination of PCT (≥0.425 ng/ml) and IL-10 (≥4.37 pg/ml) had a sensitivity of 100% (95% CI 68.8–100%) and specificity of 89% (95% CI 80.0–95.0%) for prediction of bacteraemia, correctly identifying all eight bacteraemia episodes and classifying 16 FN episodes as high-risk. There was limited additive benefit of incorporating clinical variables to this model. On Day 2, there was an 11-fold increase in PCT in episodes with a bacteraemia which was significantly higher than that observed in the non-bacteraemia episodes.ConclusionElevated PCT and IL-10 accurately identified all bacteraemia episodes in our FN cohort and may enhance the early risk stratification process in this population. Prospective validation and implementation is required to determine the impact on health service utilisation.

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Home-based care of low-risk febrile neutropenia in children—an implementation study in a tertiary paediatric hospital

Abstract: Home-based care of low-risk febrile neutropenia in children -an implementation study in a tertiary paediatric hospital.

Cited by 22 publications

References 31 publications

Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children

Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children

Managing low‐risk febrile neutropenia in children in the time of COVID‐19: What matters to parents and clinicians

Procalcitonin and Interleukin-10 May Assist in Early Prediction of Bacteraemia in Children With Cancer and Febrile Neutropenia

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