Background: The Infectious Diseases Society of America (IDSA) guidelines recommend blood cultures (bcx) for the first three days of febrile neutropenia (FN) in the clinically stable oncology patient with persistent fevers. At the University of Chicago Medicine (UCM), we assessed whether evaluating FN in the pediatric patient per IDSA guidelines would cause patient harm or affect the quality of care.
Methods: Retrospective chart review was performed for febrile neutropenic (Absolute Neutrophil Count (ANC) <500) pediatric patients from July 2009 to May 2013. FN episodes were tracked until the patient was afebrile for 72 hours. Statistical analysis of demographics and risk factors for positive bcx after day 3 included 95% confidence intervals for proportions and Chi-squared or Fisher's exact test where appropriate.
Results: Of 380 episodes of FN, 77 had a positive bcx on day 1 (20.26% incidence of bacteremia). Of 303 episodes with a negative bcx on day 1, 49.8% had a hematologic malignancy, and 50.2% had solid tumors. Of FN episodes with a negative bcx on day 1, 8 [2.64%, 95%CI +/-1.81(0.83-4.45)] had a positive bcx after day 3. Of those, 3 were pathogens [0.9%, 95%CI +/-1.06(-0.16-1.96)], and 1 was found in a clinically stable patient [0.33%, 95%CI +/-0.65(-0.32-0.98)]. In 2 patients, E. coli was isolated from bcx after day 10 in the setting of significant clinical changes. One pathogen, Streptococcus oralis, was isolated from a stable patient with new mucositis on day 13. Multiple risk factors were not statistically significant, including underlying malignancy, neutropenia duration, history of positive bcx, central venous catheter present on admission, antibiotic or antifungal presence on admission. ICU admission and mortality prior to discharge were not statistically significant when contaminants and unstable patients were removed from analysis.
Conclusion: Of 303 FN encounters, only one episode of bacteremia [0.33%, 95%CI +/- 0.65(–0.32-0.98)] occurred without change in clinical symptoms past day 3, although was seen in a patient with new mucositis. This analysis supports the IDSA guidelines to discontinue blood cultures in clinically stable FN patients after day 3.
A. H. Bartlett, None
J. Mcneer, None
K. Alexander, None
J. Pisano, None