Etiology and Clinical Course of Febrile Neutropenia in Children With Cancer

Background: The etiology, clinical course, and outcome of fever and neutropenia (FN) in children with cancer using the current FN guidelines and diagnostic resources in the United States have not been well described. Patients and Methods: Medical records of a randomly selected FN episode per patient during 2004-2005 at a pediatric oncology center were reviewed. Patients were managed as per institutional FN guidelines and blood cultures collected in continuously read BACTEC bottles. Results: Of 337 FN episodes, infection was proven in 86 (25%) and probable in 75 (22%). In all, 177 episodes (53%) were judged fever of unknown origin (FUO). Bacteremia accounted for most (41) of the proven bacterial episodes, with viridans streptococci (13), Pseudomonas spp. (6) and Escherichia coli (6) the most frequently isolated organisms. The median time to positivity of blood cultures was 12 hours (range, 5.4-143.7) with 93% positive within 24 hours of incubation. Viral pathogens were identified in 29 (34%) episodes. Compared with other patients, those with FUO had shorter median duration of fever (0.5 vs. 2.0d; P < 0.0001) and hospitalization (3 vs. 6d; P < 0.0001), longer median duration since last chemotherapy (6.0 vs. 4.0d; P = 0.01), and were less likely to have a diagnosis of acute myelogenous leukemia (11% vs. 22%; P = 0.009) or develop a clinical complication (5.1 % vs. 24.4%; P < 0.0001). Conclusions: Despite currently available diagnostic resources, the majority of patients with FN have FUO marked by a low rate of clinical complications and no infection-related mortality. Emergence of viridans streptococci as the most common blood isolate has affected FN treatment recommendations. Study findings will help further development of strategies for risk stratified management of fever with neutropenia in pediatric patients.