A lack of consistency in the management of fever and neutropenia in childhood cancer could be improved with national guidelines and a validated clinical decision rule (CDR) for risk stratification.
The recommendations follow a survey of more than 100 healthcare providers including haematology, oncology and infectious diseases consultants, registrars and nurses from 16 hospitals across Australia and New Zealand.
Participants were questioned on three clinical scenarios regarding risk assessment, empiric antibiotic choice and timing, initial investigations, IV-oral switch, ambulatory management and aminoglycoside duration.
While the majority of respondents (59-99%) correctly identified the cases as either low or high risk, there were apparent knowledge gaps and a variety of practice regarding proposed management.
“A typically low-risk FN episode was identified as high risk by a quarter of respondents, and conversely, a high-risk case was perceived as low risk by over one third,” said the study authors, led by Dr Gabrielle Haeusler, a paediatrician at the Peter MacCallum Cancer Centre, Victoria.
Failure to correctly identify a low risk case was a missed opportunity to initiate monotherapy instead of dual therapy, switch early from IV to oral administration and manage the patient within an ambulatory care program, they said.
“Similarly, the accurate identification of high-risk patients may facilitate enhanced monitoring, early treatment, and prevention of sepsis and other adverse events.”
The study said deviations from evidence-based guidelines were also evident in the use and duration of aminoglycoside and glycopeptides beyond the first 48 hours.
“In particular, over half of the haematology–oncology respondents would continue the aminoglycoside for ongoing fever despite negative blood cultures and clinical stability.”
“In addition, remaining febrile at 48 h was considered a very important factor guiding the decision to use empiric vancomycin by 30%, despite placebo-controlled trial data indicating no benefit on time to defervescence and all-cause mortality.”
The study found while a hospital or state-wide guideline was available to almost all respondents (99%), only 41% said their institute had a local CDR to distinguish high and low risk FN. Policy or guidelines for nurse-initiated FN antibiotics were infrequent.
Seven different definitions of fever were used, although just two accounted for about 86% of practice.
“National guidelines and targeted education addressing the barriers to best practice as identified in this survey, together with collaborative research efforts, have the potential to reduce unwanted variation, improve patient safety and increase ambulatory management of low-risk FN in Australia and New Zealand,” the researchers concluded.