Door-to-Needle Time for Administration of Antibiotic in Children with Cancer Within the Golden Hour- an Audit from a Tertiary Cancer Hospital in a Low-Middle Income Country
Authors: Zahan Sayeeda , KS Reghu , Bhattachharyya Parthasarathi , Ghosh Manidipa , Bhattacharyya Arpita 
Published: November 2023

Abstract

Background
Fever neutropenia (FN) is the commonest complication during treatment in children with cancer. Most guidelines recommend administration of intravenous antibiotics within 60 minutes of presentation to the Emergency Room (ER) to minimize life threatening complications of FN(1). We performed a 3-month audit at our ER to see if this target was being met(2).
The departmental FN management policy was revised and implemented from February 2021 based on the prevailing hospital antibiogram.
All children undergoing treatment in the Paediatric Oncology Department are provided with written FN Alerts/Advice (Fig. 1). All patient prescriptions include instructions on antibiotic choice and dosage.
Annual educational sessions are held with the ER staff and Paediatric Oncology Residents. A stock of essential antibiotics is maintained in the ER.

Methods
All children on chemotherapy or radiotherapy presenting to ER with fever (≥38°C) either at home or documented at ER had blood counts and blood cultures sent both from a peripheral vein and the indwelling central venous device (if present). The first dose of antibiotics as prescribed was administered without waiting for the blood count report or assessment by the Clinician.
Time of patient’s arrival at ER and time of administration of the first antibiotic dose were obtained from ER nursing records and patient drug cards. Data was entered prospectively within 24 hours and tabulated for analysis on Microsoft Excel.
Fig.1: Fever Neutropenia Sticker on Patient File

Results
Eighty-four children presented with 129 episodes of fever during the audit period (1st April 2022-30th June 2022).
Median age was 6.4 years (IQR 3.1,12).
Median time interval from last chemotherapy was 6 days (IQR 2,10).
All children reporting to ER were seen by a Clinician, with 106 (82%) episodes seen within 30 minutes of reporting (median 15 minutes, IQR 5,21).
All children received initial intravenous antibiotics after blood sampling.
Median door-to-needle time was 45 minutes (IQR 35,60 minutes)
There were 2 deaths in this cohort, one due to cancer progression and the other due to an unidentified infection of the central nervous system.

Conclusions
Over 80% children received the first dose of antibiotics within the target of &lt;60 minutes.
There were no deaths attributable to sepsis.
Though the outcome was excellent in this cohort, we need to analyse the reasons for delay in administration of the first antibiotic dose and take remedial measures to improve compliance.

References
1. Forde C, Scullin P. Chasing the Golden Hour – Lessons learned from improving initial neutropenic sepsis management. BMJ Open Qual. 2017 Mar 1;6(1):u204420.w6531.
2. Ali N, Baqir M, Hamid A, Khurshid M. Febrile neutropenia: median door-to-needle time - results of an initial audit. Hematol Amst Neth. 2015 Jan;20(1):26–30.

Acknowledgement
We would like to thank the LOTUS Network for technical support and funding to attend this conference.

Contact
Arpita Bhattacharyya
Department of Paediatric Haematology Oncology
Tata Medical Center, Kolkata, India
arpita.bhattacharyya@tmckolkata.com