Febrile neutropenia (F&N) is common among pediatric oncology patients. However, there is a lack of clarity regarding parameters whereby such patients have demonstrated adequate bone marrow recovery for hospital discharge and empiric antibiotic discontinuation.

Procedure

A retrospective review was performed for 350 episodes of F&N occurring at a single institution between 2007 and 2012 in pediatric oncology patients who were afebrile for 24 hr and had no bacterial source identified. Seven-day postdischarge outcomes were assessed and compared based on absolute neutrophil count (ANC) at discharge in order to identify an optimal threshold.

Results

Overall, 7-day readmission rates were low (17/350, 4.6%), with patients discharged with post-nadir ANC of 100–199/μl (2/51, 3.9%), 200–499/μl (5/125, 4.0%), and ≥500/μl (8/160, 5.0%), all having similar rates. Patients with a discharge ANC < 100/μl (2/14, 14.3%) had a higher readmission rate. A new bloodstream infection was identified upon readmission in one patient in each discharge ANC range except for ANC of 100–199/μl, in which none occurred. In a subset of 217 episodes where the ANC fell below 200/μl during the admission and subsequently rose above 100/μl, 94 episodes resulted in 126 additional hospital days while subjects awaited further count recovery. One death occurred in a patient whose ANC at discharge was 290/μl. This patient had received additional chemotherapy after count recovery and prior to discharge, and was readmitted with Clostridium tertium bacteremia.

Conclusion

These results suggest that a post-nadir ANC > 100/μl is a safe threshold value for empiric antibiotic discontinuation and discharge home.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

Supporting Information

REFERENCES

1Furno P, Bucaneve G, Del Favero A. Monotherapy or aminoglycoside-containing combinations for empirical antibiotic treatment of febrile neutropenic patients: a meta-analysis. Lancet Infect Dis. 2002; 2(4): 231–242.
10.1016/S1473-3099(02)00241-4
CAS PubMed Web of Science® Google Scholar
2Manji A, Lehrnbecher T, Dupuis LL, et al. A meta-analysis of antipseudomonal penicillins and cephalosporins in pediatric patients with fever and neutropenia. Pediatr Infect Dis J. 2012; 31(4): 353–358.
10.1097/INF.0b013e318242590e
PubMed Web of Science® Google Scholar
3Lehrnbecher T, Phillips R, Alexander S, et al. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol. 2012; 30(35): 4427–4438.
10.1200/JCO.2012.42.7161
PubMed Web of Science® Google Scholar
4Griffin TC, Buchanan GR. Hematologic predictors of bone marrow recovery in neutropenic patients hospitalized for fever: implications for discontinuation of antibiotics and early discharge from the hospital. J Pediatr. 1992; 121(1): 28–33.
10.1016/S0022-3476(05)82536-3
CAS PubMed Web of Science® Google Scholar
5Aquino VM, Buchanan GR, Tkaczewski I, et al. Safety of early hospital discharge of selected febrile children and adolescents with cancer with prolonged neutropenia. Med Pediatr Oncol. 1997; 28(3): 191–195.
10.1002/(SICI)1096-911X(199703)28:3<191::AID-MPO7>3.0.CO;2-E
CAS PubMed Web of Science® Google Scholar
6Bash RO, Katz JA, Cash JV, et al. Safety and cost effectiveness of early hospital discharge of lower risk children with cancer admitted for fever and neutropenia. Cancer. 1994; 74(1): 189–196.
10.1002/1097-0142(19940701)74:1<189::AID-CNCR2820740130>3.0.CO;2-7
CAS PubMed Web of Science® Google Scholar
7Mullen CA, Buchanan GR. Early hospital discharge of children with cancer treated for fever and neutropenia: identification and management of the low-risk patient. J Clin Oncol. 1990; 8(12): 1998–2004.
10.1200/JCO.1990.8.12.1998
CAS PubMed Web of Science® Google Scholar
8Aquino VM, Tkaczewski I, Buchanan GR. Early discharge of low-risk febrile neutropenic children and adolescents with cancer. Clin Infect Dis. 1997; 25(1): 74–78.
10.1086/514512
PubMed Web of Science® Google Scholar
9Mueller EL, Walkovich KJ, Yanik GA, et al. Variation in management of fever and neutropenia among pediatric patients with cancer: a survey of providers in Michigan. Pediatr Hematol Oncol. 2015; 32(5): 331–340.
10.3109/08880018.2015.1036331
PubMed Web of Science® Google Scholar
10Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011; 52(4): 427–431.
10.1093/cid/ciq147
PubMed Web of Science® Google Scholar
11Bhatnagar S, Chandra J, Narayan S. Hematological changes and predictors of bone marrow recovery in patients with neutropenic episodes in acute lymphoblastic leukemia. J Trop Pediatr. 2002; 48(4): 200–203.
10.1093/tropej/48.4.200
PubMed Web of Science® Google Scholar
12 Team RC. R: A language and environment for statistical computing. version 3.3. Vienna, Austria: R Foundation for Statistical Computing; 2017.
Google Scholar
13Cohen KJ, Leamer K, Odom L, et al. Cessation of antibiotics regardless of ANC is safe in children with febrile neutropenia. A preliminary prospective trial. J Pediatr Hematol Oncol. 1995; 17(4): 325–330.
10.1097/00043426-199511000-00008
CAS PubMed Web of Science® Google Scholar
14Lehrnbecher T, Stanescu A, Kuhl J. Short courses of intravenous empirical antibiotic treatment in selected febrile neutropenic children with cancer. Infection. 2002; 30(1): 17–21.
10.1007/s15010-002-2094-1
CAS PubMed Web of Science® Google Scholar
15Hodgson-Viden H, Grundy PE, Robinson JL. Early discontinuation of intravenous antimicrobial therapy in pediatric oncology patients with febrile neutropenia. BMC Pediatr. 2005; 5(1): 10.
10.1186/1471-2431-5-10
PubMed Google Scholar
16Villanueva MA, August KJ. Early discharge of neutropenic pediatric oncology patients admitted with fever. Pediatr Blood Cancer. 2016; 63(10): 1829–1833.
10.1002/pbc.26072
PubMed Web of Science® Google Scholar
17Rondinelli PI, Ribeiro Kde C, de Camargo B. A proposed score for predicting severe infection complications in children with chemotherapy-induced febrile neutropenia. J Pediatr Hematol Oncol. 2006; 28(10): 665–670.
10.1097/01.mph.0000212996.94929.0b
PubMed Web of Science® Google Scholar
18Allen RC, Holdsworth MT, Johnson CA, et al. Risk determinants for catheter-associated blood stream infections in children and young adults with cancer. Pediatr Blood Cancer. 2008; 51(1): 53–58.
10.1002/pbc.21497
PubMed Web of Science® Google Scholar

Citing Literature

Volume65, Issue3

March 2018

e26875

Safety of discharge for children with cancer and febrile neutropenia off antibiotics using absolute neutrophil count threshold values as a surrogate marker for adequate bone marrow recovery

Abstract

Background

Procedure

Results

Conclusion

CONFLICT OF INTEREST

Supporting Information

REFERENCES

Citing Literature

References

Information

About Wiley Online Library

Help & Support

Opportunities

Connect with Wiley

Safety of discharge for children with cancer and febrile neutropenia off antibiotics using absolute neutrophil count threshold values as a surrogate marker for adequate bone marrow recovery

Abstract

Background

Procedure

Results

Conclusion

CONFLICT OF INTEREST

Supporting Information

REFERENCES

Citing Literature

References

Related

Information