Management of fever and neutropenia in children with cancer: A survey of Australian and New Zealand practice

Haeusler, Gabrielle M; Slavin, Monica A; Bryant, Penelope A; Babl, Franz E; Méchinaud, Françoise; Thursky, Karin

doi:10.1111/jpc.13899

Cited by 20 publications

(27 citation statements)

References 23 publications

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“…Children with cancer and febrile neutropenia (FN) are a heterogeneous group with varying risk of infection. This heterogeneity is not always reflected in management, with many clinicians and centres treating all patients with intravenous antibiotics, irrespective of underlying risk [1,2]. This is contrary to international paediatric FN guideline recommendations that centres 'adopt a validated risk stratification strategy and incorporate it into practice [3].…”

Section: Introductionmentioning

confidence: 97%

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Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

et al. 2020

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A B S T R A C TBackground: Reduced intensity treatment of low-risk febrile neutropenia (FN) in children with cancer is safe and improves quality of life. Identifying children with low-risk FN using a validated risk stratification strategy is recommended. This study prospectively validated nine FN clinical decision rules (CDRs) designed to predict infection or adverse outcome. Methods: Data were collected on consecutive FN episodes in this multicentre, prospective validation study. The reproducibility and discriminatory ability of each CDR in the validation cohort was compared to the derivation dataset and details of missed outcomes were reported. Findings: There were 858 FN episodes in 462 patients from eight hospitals included. Bacteraemia occurred in 111 (12¢9%) and a non-bacteraemia microbiological documented infection in 185 (21¢6%). Eight CDRs exhibited reproducibility and sensitivity ranged from 64% to 96%. Rules that had >85% sensitivity in predicting outcomes classified few patients (<20%) as low risk. For three CDRs predicting a composite outcome of any bacterial or viral infection, the sensitivity and discriminatory ability improved for prediction of bacterial infection alone. Across all CDRs designed to be implemented at FN presentation, the sensitivity improved at day 2 assessment. Interpretation: While reproducibility was observed in eight out of the nine CDRs, no rule perfectly differentiated between children with FN at high or low risk of infection. This is in keeping with other validation studies and highlights the need for additional safeguards against missed infections or adverse outcomes before implementation can be considered.

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Section: Introductionmentioning

confidence: 97%

“…Across Australia, home-based or reduced intensity treatment of children with FN identified as low-risk of infection or adverse outcome is not standard of care [2]. Availability of validated CDRs to assist in the identification of these patients has the potential to increase the uptake of dedicated low-risk FN care pathways.…”

Section: Introductionmentioning

confidence: 99%

Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

et al. 2020

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“…Regarding infectious complications, there are increasing global efforts to adopt similar risk-adapted approaches to prediction, prevention and treatment [2]. Specifically, risk stratification in fever and neutropenia (FN), one of the most common complications of care, is recommended although widespread uptake has not been realised [3][4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

et al. 2020

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Background: Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. Methods: Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). Findings: Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to nonrecalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. Interpretation: Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN.

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“…Despite this consensus, previous surveys performed in pediatric cancer centers from different countries revealed a high level of heterogeneity in many key topics of clinical management [ 3 – 8 ]. In May 2016, the working group for infectious complications in the immunocompromised child of the German Society for Pediatric Oncology and Hematology (GPOH) and the German Society for Pediatric Infectious Diseases (DGPI) released consensus recommendations [ 9 ], concerning the diagnostics and treatment of fever without a focus on neutropenic pediatric cancer patients (FN), excluding hematopoietic stem cell transplant recipients and children and adolescents with clinical signs of sepsis, septic shock or infection-related organ failure.…”

Section: Introductionmentioning

confidence: 99%

Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland

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Purpose Investigation of the current practice of diagnostics and treatment in pediatric cancer patients with febrile neutropenia. Methods On behalf of the German Society for Pediatric Oncology and Hematology and the German Society for Pediatric Infectious Diseases, an Internet-based survey was conducted in 2016 concerning the management of febrile neutropenia in pediatric oncology centers (POC). This survey accompanied the release of the corresponding German guideline to document current practice before its implementation in clinical practice. Results In total, 51 POCs participated (response rate 73%; 43 from Germany, and 4 each from Austria and Switzerland). Identified targets for antimicrobial stewardship concerned blood culture diagnostics, documentation of the time to antibiotics, the use of empirical combination therapy, drug monitoring of aminoglycosides, the time to escalation in patients with persisting fever, minimal duration of IV treatment, sequential oral treatment in patients with persisting neutropenia, indication for and choice of empirical antifungal treatment, and the local availability of a pediatric infectious diseases consultation service. Conclusion This survey provides useful information for local antibiotic stewardship teams to improve the current practice referring to the corresponding national and international guidelines. Electronic supplementary material The online version of this article (10.1007/s15010-020-01462-z) contains supplementary material, which is available to authorized users.

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Management of fever and neutropenia in children with cancer: A survey of Australian and New Zealand practice

Cited by 20 publications

References 23 publications

Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland

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