Fever and neutropenia (FN) is a major side effect of chemotherapy in pediatric oncology patients and can result in hospitalization, morbidity, or mortality. Cancer patients are at increased risk for bacteremia due to immunosuppression and their central venous catheters (CVC). Guidelines for the management of FN exist and inpatient admission with empiric parenteral antibiotics for high risk children with severe neutropenia (Absolute Neutrophil Count (ANC) ≤ 500/µl) is often the standard of care. However, the management of mildly neutropenic or non-neutropenic patients is variable across institutions. The goal of this single-institution study is to assess the safety and efficacy of our algorithm for the outpatient management of FN in "Low Risk" designated oncology patients with a CVC at CHOC Children's Hospital.
Febrile oncology patients with a CVC are managed according to our "Low Risk" Outpatient Care Guidelines based on the following criteria: patients are well appearing and outpatient at the time of initial fever, have an ANC >500, do not have any "High Risk" features or allergy to cephalosporin. "Low Risk" patients with fever have their blood culture drawn from their central line and intravenous (IV) Ceftriaxone is administered with the initial dose in the outpatient setting. The patients subsequently return the next day for follow-up and the second dose of Ceftriaxone. If their fever persists to the 3rd day or if the blood culture is positive, the patient is admitted for inpatient parenteral antibiotics.
A retrospective review of medical records was performed for patients treated according to these criteria who presented to the outpatient setting with fever from April 2014-March 2016.
In the two year time period, 96 febrile episodes in 68 patients were treated according to our "Low Risk" Outpatient Care Guidelines (Table 1). The average age, temperature, and ANC was 7.2 years, 101.2 degrees, and 4443.1/µl, respectively. Eighty-five (88.5%) patients had leukemia, the most common being B-ALL in 77 patients. The majority had portacaths, while four episodes had broviacs.
Sixty of 96 encounters (62.5%) presented with fever without an identifiable source. Only three of 96 episodes had bacteremia (3.1%). Isolated organisms from these 3 patients' CVC include Streptococcus thoraltensis and Staphylococcus epidermidis. These 3 patients, as per the Care Guidelines, were admitted inpatient for parenteral antibiotics due to their positive blood culture.
Seventy patient episodes (72.9%) were treated successfully with outpatient Ceftriaxone with subsequent resolution of their fever and negative blood cultures. Twenty-three encounters that were safely treated in the outpatient setting had an identifiable infectious source, and 22 of those (95.7%) were upper respiratory infections (URI's) or pneumonias. Twenty-six of the 96 encounters (27.1%) resulted in admission. The majority of the admissions were due to fevers that persisted >3 days. Of the 26 encounters admitted, 13 (50%) had an identifiable source of infection such as a URI, infectious diarrhea, urinary tract infection (UTI), or bacteremia (in 3 patients).
This study demonstrates that our institution's outpatient management guideline for FN in "Low Risk" designated oncology patients with an indwelling catheter is safe and feasible. Seventy encounters out of 96 did not require hospital admission and were sent home safely from the outpatient setting for follow-up the next day. Of the three encounters who had a positive blood culture, all were age 6 or younger, 2 were male, and 1 had a broviac. All three of these encounters were not neutropenic (ANC 4099-6900) and presented with no unusual symptoms. This underlines the importance of prompt blood cultures and antibiotic administration in all patients with fever in our diagnostic evaluation. While 27.1% of the febrile encounters resulted in admission, all were safely admitted within three days, per protocol, due to persistent fever. Our study shows that outpatient management of a subset of patients who fit the "Low Risk" criteria is safe, feasible and effective. There are many benefits of outpatient management of FN. Patient and family quality of life is higher, hospital costs are lower, and hospital-acquired infections decrease. Our next study will prospectively analyze whether oral antibiotics are a safe and effective option in this subset of patients.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.