Outcomes and Disposition of Oncology Patients With Non-neutropenic Fever and Positive Blood Cultures

Abstract

Children with cancer and non-neutropenic fever (NNF) episodes are often treated as outpatients if they appear well. However, a small subset have bloodstream infections (BSIs) and must return for further evaluation. These patients may be directly admitted to inpatient units, whereas others are first evaluated in outpatient settings before admission. The best practice for securing care for patients discovered to have outpatient bacteremia are unclear. To determine outcomes and compare time to antibiotics between the 2 disposition, we retrospectively reviewed all NNF initially treated as outpatients and later had positive blood cultures from 2012 to 2016. Of 845 NNF cases initially treated in outpatient settings, 48 episodes (n=43 patients) had BSIs. Of those, 77.1% (n=37) were re-evaluated as outpatients and admitted; 14.6% (n=7) were direct admissions. The median time to antibiotic did not significantly differ between outpatient re-evaluations (119 min) and direct admissions (191 min), P=0.11. One patient met sepsis criteria upon return and required intensive care unit admission for vasopressor support. No patient died within 1 week of the febrile episode. Most patients with NNF and BSIs initially discharged are stable upon return. Institutions should evaluate their patient flows to ensure that patients receive timely care.

Infections during Non-Neutropenic Episodes in Pediatric Cancer Patients—Results from a Prospective Study in Two Major Large European Cancer Centers

“…Similar results have been described in a study in pediatric patients with leukemia and solid tumors, which reported on 20% versus 3% of bacteremia in neutropenic and non-neutropenic episodes, respectively [15]. In our analysis, all but one bloodstream infection in non-neutropenic patients were due to a Grampositive pathogen, whereas previous data report on a relevant percentage of Gram-negative pathogens also in the non-neutropenic setting [10][11][12], which might be related to the presence of mucositis and barrier damage of the gut in these patients. Whether biomarkers such as procalcitonin are reliable in distinguishing Gram-positive from Gram-negative infections in pediatric cancer patients need to be evaluated in large clinical trials [16].…”

“…In contrast to well established guidelines in pediatric cancer patients presenting with febrile neutropenia [ 3 , 4 , 5 ], data on infections with onset during a non-neutropenic period are limited in children with cancer [ 8 , 10 , 11 ]. Therefore, it is not surprising that the clinical approach in this setting varies widely across institutions [ 9 ], and the use of fluoroquinolones is controversial [ 4 , 8 ].…”

Bloodstream Infections in Pediatric Oncology Patients: Bacterial Pathogen Distribution and Antimicrobial Susceptibility at the University Hospital Centre Zagreb, Croatia—A 5-Year Analysis

“…It refers to the higher prevalence of Klebsiella spp. in neutropenic and, vice versa, CoNS in patients without neutropenia 29–32 . Increased CoNS prevalence in patients without neutropenia may result from frequent CVC usage; however, our definition of BSI may potentially have limitations.…”

“…in neutropenic and, vice versa, CoNS in patients without neutropenia. [29][30][31][32] Increased CoNS prevalence in patients without neutropenia may result from frequent CVC usage; however, our definition of BSI may potentially have limitations. The number of positive blood culture sets was used to exclude contaminants; however, it can be challenging to differentiate between actual blood culture contamination and true-positive blood culture when blood culture sets were obtained from the CVC alone (which is in concordance with current guidelines), rather than the peripheral vein.…”

The Yield, Safety, and Cost-effectiveness of Decreasing Repeat Blood Cultures Beyond 48 Hours in a Pediatric Hematology-Oncology Unit

“…Inpatient admissions are common and costly for pediatric oncology patients, 1,2 and are often the result of fever, febrile neutropenia (FN), or suspected infection 3,4 . Yet, the underlying cause of fever in both neutropenic 5–10 and non-neutropenic 11–16 children with cancer often remains unknown with negative blood cultures (BCxs). With mortality rates now as low as 0.6% to 3.0% in pediatric oncology patients hospitalized for FN, 5,7,9 there is a need to identify patients in whom fewer BCx may be safely obtained.…”