Assessing Safe Discharge Criteria for Pediatric Oncology Patients Admitted for Febrile Neutropenia

Background: Febrile neutropenia is a common complication of myelosuppression secondary to chemotherapy. In many cases, no source of infection is found. Many pediatric oncology centers continue inpatient parenteral antibiotics therapy until myelorecovery is seen. Multiple studies suggest that outpatient therapy, oral antibiotics, or earlier discharge could be appropriate alternative treatments in some patients, supporting data are lacking. Current Children's Oncology Group guidelines recommend considering discontinuing empiric antibiotics at 72 hours in low risk patients with negative blood cultures for at least 24 hours irrespective of marrow recovery. However, this is a weak recommendation with only moderate quality evidence. With limited supporting evidence febrile neutropenia management and hospitalization duration vary by institution and individual provider.

Methods: We performed a retrospective chart review of patients admitted to the Pediatric Hematology/Oncology service from September 2005 through October 2016, using ICD-9 or ICD-10 codes for "febrile neutropenia", "neutropenia", or "fever", generating a list of 1555 charts. Duplicate charts, patients with fever or neutropenia but not both, and those with non-oncologic diagnoses, were eliminated, leaving 729 febrile neutropenia admissions. Of these, 131 were considered to be "early discharges" defined as discharged home at 4 or less days with discharge ANC < 500 and negative cultures. All were afebrile by the time of discharge and were released without outpatient antibiotics. These charts were then reviewed for subsequent readmission within the next 4 days.

Results: 11 of the 131 patients (8%) were readmitted for reasons other than chemotherapy. 2 patients were called back from the initial admission for late positive cultures, one for Proprionibacter acnes bacterium for whom repeat cultures were negative and the second for coagulase negative staphylococcus, initially thought to be a contaminant but a second blood culture, collected prior to the initial discharge, was positive. The other 9 were readmitted with febrile neutropenia. Of these, 2 had positive cultures on readmission, 1 for pseudomonas aeruginosa and 1 for E. coli. All 4 patients with positive cultures remained stable and were safely treated with appropriate antibiotics. The remaining 7 patients had uneventful admissions and were discharged once again when afebrile with negative cultures. The mean age of the readmitted patients was younger than those not readmitted (4.2 yrs vs 7 yrs, p=0.003). The average ANC (standard deviation) at discharge was lower for the patients who were readmitted versus those not readmitted (69 (70) vs 198 (147), p=<0.001), as was APC on admission (165 (254) vs 321 (388), p=<0.001) and APC at discharge (97 (82) vs 453 (431), p=<0.001). The readmitted patients had a non-significant trend toward decline in ANC from initial admission to discharge, while those not readmitted had a slight increase in ANC (DANC -75 (211) vs +38 (209), p=0.065). Review of graphs of these values showed that use of the highest value for the readmitted patients as a cutoff would result in a large percentages of the non-readmitted patients remaining in the hospital. There was no difference with regard to gender, type of malignancy, or ANC on admission between the two cohorts.

Conclusion: This retrospective review showed that low risk patients admitted with febrile neutropenia could be safely discharged prior to count recovery without oral antibiotics. Only a small percentage of patients required readmission for repeat fevers while still neutropenic, and those with bacterial infections were easily identified on readmission and appropriately treated. Not surprisingly, the readmitted group had a lower discharge ANC and APC than those not readmitted. However all patients remained stable and none suffered adverse events. Overall, 120/131 (92%) of patients deemed low risk were able to be discharged early without incident. Applying higher ANC or APC criteria for discharge would result in increased length of hospital stay for a significant population of low risk children without decreasing morbidity.

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