14: Severe Neutropenia with Fever in Previously Healthy Children: Do they all Need Broad-Spectrum Antibiotics?

Abstract

Background: Previously healthy children often present to the emergency room with fever. When complete blood count shows isolated neutropenia, these patients are often hospitalised and treated with broad-spectrum antibiotics. This approach for patients with febrile neutropenia (FN) is a clear standard of care recommended by various guidelines. However, such recommendations are based upon studies on chemotherapy and cancerrelated neutropenia. Whether these recommendations are applicable to children with non-oncological neutropenia, including viral-induced or benign neutropenia, remains poorly studied. Objectives: Our objective was to describe the outcomes of children with fever and de-novo neutropenia. Design/Methods: Through a six-year (April 1, 2005 to March 31, 2011) retrospective cohort study at a tertiary pediatric hospital, we reviewed the outcomes of patients who presented to the emergency room with non-oncological, isolated severe FN (absolute neutrophil count (ANC) <0.5x109/L, and temperature >38.5degreeC). All patients with prior history of cancer, chemotherapy, bone marrow transplant, known neutropenia and children <3 months of age were excluded from this study. Results: Forty-seven children, median age of 1.1 years (range 0.3 to 6.1), were included in this study. Median ANC on admission was 0.2x109/L. Seasonal variation with higher incidence in fall and spring was observed. Broad-spectrum antibiotics were given in 91.4% of cases. Six patients had suspected bacterial infections: three (6.4%) had a urinary tract infection, one (2.1%) had pneumonia, and one (2.1%) had a peritonsillar abscess. Only one patient had a severe presentation with a rapidly controlled compensated shock and the outcome was favourable. Although an external ear canal culture revealed pseudomonas aeruginosa, blood, CSF and urine cultures remained negative for this patient. The vast majority of patients, 37 children (78.7%), received a final diagnosis of probable viral infection and four patients (8.5%) had a discharge diagnosis of FN (unspecified cause). All patients had favourable outcomes with a median hospital stay of three days. None had positive blood cultures. Conclusions: In this study, the rate of severe bacterial infections in children with non-oncological FN is low, contrasting with a rate of 10% to 20% of documented bacteremia, and a up to 45% of invasive infections in oncology patients. Well-appearing children with non-oncological FN may not require intravenous antibiotics or hospitalisation, but should be closely followed. Physicians could therefore rely on the presence of other clinical findings such as patient appearance and possible source for bacterial infection in order to make such a decision. The safety of such an approach warrants further prospective studies.