Outcome of Oncologic Pediatric Patients Presenting with Febrile Neutropenia after Implementation of the Standard of Procedure in the Outpatient Department
Authors: Malvestiti Stefano , Strahm Brigitte , Flotho Christian , Hettmer Simone , Hufnagel Markus , Feuchtinger Tobias , Niemeyer Charlotte Marie , Puzik Alexander 
Published: December 2024

Introduction: Febrile neutropenia (FN) is a common complication in paediatric patients receiving chemotherapy and ranks among the most common causes of death in patients with cancer. The standard of care is the rapid identification of high-risk patients upon presentation in the emergency room (ER) and initiation of appropriate diagnostic and therapeutic measures. The prompt administration of broad-spectrum antibiotics appeared to reduce morbidity and mortality in all cancer patients developing FN. The interval between admission and antibiotics administration, also referred as time-to-antibiotics (TTA), has therefore been used as a quality-of-care benchmark in cancer treatment.

Primary objective: To assess the effect of a change of a standard of procedure (SOP) for the treatment of FN on the TTA in pediatric cancer patients receiving chemotherapy.

Secondary objective: To assess the clinical impact of the new SOP on the course of FN episodes in pediatric cancer patients.

Study design: This retrospective, single-center, cohort study included pediatric cancer patients presenting with FN in the emergency room (ER) or in the outpatient department of the pediatric hematology and oncology clinic (OD) of the Medical Center of the University of Freiburg from May 2019 until May 2021. Median TTA before and after the introduction of the new SOP, i.e. May 2020, was compared, as well as the occurrence of adverse events during FN episodes. A target TTA ≤ 30 minutes was demanded within the new SOP, compared to no target TTA in the previous SOP. The primary endpoint was defined as fulfilment of target TTA in &gt;50% of FN episodes. Secondary endpoints comprised the rate of complications occurring during FN episodes (e.g. admission in ICU, use of vasopressors, need of respiratory support).

Results: 227 Episodes of FN were included in this study. The primary endpoint was not met, as target TTA was achieved in 32.9% of cases only. However, a significant reduction of the median TTA was observed (93 min vs. 44 min). The improvement of median TTA persisted during the study period. The presence of tachycardia and fever at presentation were associated with shorter TTA. Higher CRP values related to increased hospital length of stay and higher rate of complications during the FN episodes.

Conclusions: This study highlights how simple implementations of a procedural algorithm even in large pediatric cancer centers can have a significant impact on the quality of care, e.g. on TTA in FN. Our SOP appears as an effective approach with longer lasting effects to improve care of FN in children with cancer. However, the retrospective study design is a major limitation that might obscure the relationship between SOP effects, TTA and patient outcome in FN episodes. Prospective evaluations of standardized procedures may further improve guidelines for the treatment of FN.