A North American Survey of the Management Practice of Prolonged Pediatric Febrile Neutropenia

Author Type(s)

Faculty, Resident/Fellow

Document Type

Abstract

Publication Date

2022

DOI

Pediatric Blood and Cancer 10.1002/pbc.29735

Journal Title

Pediatric Blood and Cancer

Department

Pediatrics

Abstract

Background: Febrile neutropenia (FN) is a common result of chemotherapy leading to life-threatening illness. The International Pediatric Fever and Neutropenia Guideline Panel issued guidelines in 2012 (updated in 2017) on the management of FN in children with cancer or recipients of hematopoietic stem cell transplants (HSCT) to provide guidance for management of prolonged FN. These guidelines recommend obtaining peripheral cultures at presentation (weak recommendation), initiating antipseudomonal monotherapy without modification except for changes in clinical status (strong recommendation), avoiding the use of empiric antifungal therapy except for patients with high risk of invasive fungal disease (strong recommendation), and not using galactomannan and β-D-glucan to evaluate for invasive fungal disease (weak recommendation and strong recommendation, respectively). The need for obtaining repeat blood cultures beyond 72 hours is unclear in pediatric FN, but recommended against in adult FN. Objectives: Determine physician management of FN on days 1, 4, 5, and 7 with fever in the setting of negative blood cultures, in patients with ALL (acute lymphoblastic leukemia), neuroblastoma (NB), and acute myeloid leukemia (AML) or HSCT. Design/Method: An electronic survey consisting of practice-pattern questions was sent to 1,631 pediatric hematologist/oncologists in the US and Canada. 162 complete responses were recorded for questions relating to ALL and neuroblastoma, 115 for AML, and 37 for HSCT. Results: 99.7% of respondents obtain ≥1 central venous catheter blood culture at presentation with 31% also obtaining peripheral blood cultures. Blood cultures on subsequent days of fever are obtained more frequently in the HSCT subgroup (96%) compared to the other groups (ALL (85%), p = 0.03; NB (87%), p = 0.022; and AML (89%), p = 0.044) and overall, more frequently in the AML/HSCT subgroup compared to ALL/NB (93% vs 86%; p = 0.03). 92% of respondents initiate empirical antipseudomonal monotherapy for ALL/NB patients compared to 43% for AML/HSCT patients (p = 0.002). The AML/HSCT subgroup is more likely to be treated with vancomycin compared to the ALL/NB subgroup both on presentation (54% vs 4%; p = 0.025) and overall (61% vs 28%; p = 0.004). Aminoglycoside use is less frequent, and used similarly in AML/HSCT patients as compared to ALL/NB patients (10% vs 7%; p = 0.12). For FN lasting ≥96 hours, 81% of physicians test for fungal disease, sending fungal cultures (56%), serum galactomannan (72%), and/or β-D-glucan (52%), and 76% initiating antifungal therapy. Conclusion: Physician practice deviates from pediatric specific guidelines for the management of FN. Further research is needed to understand the basis for these practice pattern differences.

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