Nonneutropenic fever in children with cancer: A scoping review of management and outcome

Allaway, Zoe; Phillips, Bob; Thursky, Karin; Haeusler, Gabrielle M

doi:10.1002/pbc.27634

Cited by 20 publications

(34 citation statements)

References 32 publications

(291 reference statements)

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“…Our time prior to admission was 1 day that shorter previous studies (Vathana et al, 2017;Sanpakit et al, 2005). Median ANC is <100 mm3 which is similar (Vathana et al, 2017;Sanpakit et al, 2005;Allaway et al, 2019).…”

Section: Discussionsupporting

confidence: 67%

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Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia

Thangthong

Anugulruengkitt

Lauhasurayotin

et al. 2020

Asian Pac J Cancer Prev

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Objectives: Febrile neutropenia (FN) is severe and potentially life-threatening in oncologic patients. The objective of this study is to define the factors associated with severe adverse outcomes of pediatric FN. Methods: A retrospective and prospective descriptive study performed in pediatric patients diagnosed with FN at King Chulalongkorn Memorial Hospital from January 2013 to December 2017. Severe adverse events defined as the presence in one of these following oxygen therapies, mechanical ventilator, shock, admission to ICU, renal dysfunction, and liver dysfunction. Results: The study included 267 patients with 563 febrile neutropenia episodes. The median (range) age was 5.1 years (1 month-15 year). Among 563 febrile neutropenia episodes, 115 episodes (20%) developed severe adverse events. The FN patients were classified into low and high-risk groups, 91% of patients with severe adverse events and all 21 patients who died were in high risk group. The overall mortality rate was 3.1%. Factors associated with severe adverse events were fungal infection (aOR 6.51, 95%CI 2.29-18.56), central venous catheter insertion (aOR 4.28, 95% CI 2.51-7.29), CPG defined high risk (aOR 3.35, 95%CI 1.56-7.17), viral infection (aOR 2.72, 95%CI 1.05-7.06), lower respiratory tract infection (aOR 2.52, 95%CI 1.09-5.82) and treatment not according to CPG (aOR 2.47, 95% CI 1.51-4.03). Conclusions: Fungal and viral infection, central venous catheter insertion, lower respiratory tract infection, CPG defined high risk and treatment not according to CPG were associated factors of increased risk for severe adverse events. Our current institutional CPG for FN in children was applicable and improved clinical outcomes for this group of patients.

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Section: Discussionsupporting

confidence: 67%

“…It has been reported that risk factors for severe infection in children with cancer or HCT recipients include (Freifeld et al, 2011): chemotherapy intensity, central venous catheter insertion (Allaway et al, 2019) breakdown of skin and mucosal barriers (e.g. mucositis).…”

Section: Discussionmentioning

confidence: 99%

Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia

Thangthong

Anugulruengkitt

Lauhasurayotin

et al. 2020

Asian Pac J Cancer Prev

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“…Across all sites the number of children with cancer presenting to hospital with non-neutropenic fever (NNF) exceeded the number with FN. This burden is previously unrecognised as reflected by the paucity of NNF studies and the absence of guidelines [48]. To date, only one risk-prediction rule has been derived in children with NNF .…”

Section: Discussionmentioning

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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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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“…Bacteremia is rare in pediatric patients with NNF, occurring in approximately 4-10% of febrile episodes, and outcomes for these patients who lack concerning clinical features are excellent. 6 NNF is most commonly treated with CTX alone, which is a 3 rd generation cephalosporin that does not cover pseudomonas aeruginosa and is prone to bacterial resistence 11 . The rate of bacteremia in patients with F&N is higher, ranging from 16-25%, but bacteremia due to pseudomonas aeruginosa is quite rare, ranging from only 4-7% of cases with documented bacteremia [12][13][14][15] .…”

Section: Delays In Antibiotic Choicementioning

confidence: 99%

A Quality Improvement Initiative: Improving Time-to-Antibiotics for Pediatric Oncology Patients with Fever and Suspected Neutropenia

Kram

Salafian

et al. 2020

Preprint

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BackgroundThere is a high risk for adverse outcomes in immunocompromised, neutropenic pediatric oncology patients with fever if antibiotics are not received in a timely manner. As the absolute neutrophil count is typically unknown at the onset of fever, rapid antibiotic administration for all pediatric oncology patients with fever and suspected neutropenia is critical.Local ProblemDespite efforts over the years to meet the standard of time-to-antibiotic delivery to within 60 minutes of arrival, audits revealed a prolonged and wide-ranging time-to-antibiotics in our pediatric emergency department.MethodsWe conducted a quality improvement initiative to reduce the time to antibiotic delivery for this high risk patient population. The setting was a pediatric emergency department in an academic tertiary care hospital. We assembled a multidisciplinary team to apply quality improvement methods to understand the problem, implement interventions, and evaluate the outcomes.InterventionsWe targeted delays in patient triage, delays in antibiotic ordering, delays in antibiotic choice, and delays in bedside indwelling Port-a-Cath accessing procedure. Among other interventions, we instituted three unique measures: ceftriaxone was administered to all pediatric oncology patients with suspected neutropenia and fever; a system of ordering antibiotics that was driven by the ED pharmacist obtaining a verbal order from the ED attending; and a nurse-driven order set triggered by a unique triage category which empowered nurses to access a patient’s central line, draw and send specified blood work, and deliver an intravenous antibiotic, all potentially before an ED provider sees the patient.ResultsOver a sustained 3 year period of time, the percentage of febrile oncology patients with suspected neutropenia who met the target time-to-antibiotic delivery rose from 51% to 96%. The mean time-to-antibiotic delivery fell from 58 minutes in the pre-intervention period to 28 minutes in the post-intervention period.ConclusionsThe interventions implemented by the multidisciplinary team, using quality improvement methodology, successfully improved the percentage of febrile oncology patients receiving antibiotics within 60 minutes of arrival to a pediatric emergency department.

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Nonneutropenic fever in children with cancer: A scoping review of management and outcome

Cited by 20 publications

References 32 publications

Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia

Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia

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

A Quality Improvement Initiative: Improving Time-to-Antibiotics for Pediatric Oncology Patients with Fever and Suspected Neutropenia

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