Non-neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation

Prospective External Validation of the Esbenshade Vanderbilt Models Accurately Predicts Bloodstream Infection Risk in Febrile Non-Neutropenic Children With Cancer

PURPOSE

The optimal management of fever without severe neutropenia (absolute neutrophil count [ANC] ≥500/µL) in pediatric patients with cancer is undefined. The previously proposed Esbenshade Vanderbilt (EsVan) models accurately predict bacterial bloodstream infections (BSIs) in this population and provide risk stratification to aid management, but have lacked prospective external validation.

MATERIALS AND METHODS

Episodes of fever with a central venous catheter and ANC ≥500/µL occurring in pediatric patients with cancer were prospectively collected from 18 academic medical centers. Variables included in the EsVan models and 7-day clinical outcomes were collected. Five versions of the EsVan models were applied to the data with calculation of C-statistics for both overall BSI rate and high-risk organism BSI (gram-negative and Staphylococcus aureus BSI), as well as model calibration.

RESULTS

In 2,565 evaluable episodes, the BSI rate was 4.7% (N = 120). Complications for the whole cohort were rare, with 1.1% (N = 27) needing intensive care unit (ICU) care by 7 days, and the all-cause mortality rate was 0.2% (N = 5), with only one potential infection-related death. C-statistics ranged from 0.775 to 0.789 for predicting overall BSI, with improved accuracy in predicting high-risk organism BSI (C-statistic 0.800-0.819). Initial empiric antibiotics were withheld in 14.9% of episodes, with no deaths or ICU admissions attributable to not receiving empiric antibiotics.

CONCLUSION

The EsVan models, especially EsVan2b, perform very well prospectively across multiple academic medical centers and accurately stratify risk of BSI in episodes of non-neutropenic fever in pediatric patients with cancer. Implementation of routine screening with risk-stratified management for non-neutropenic fever in pediatric patients with cancer could safely reduce unnecessary antibiotic use.

Epidemiology of bloodstream infections and the impact of antimicrobial resistance in pediatric hematopoietic cell transplant

Bloodstream infections (BSI) pose a substantial threat to the well-being and survival of patients undergoing hematopoietic stem cell transplantation (HSCT). Risk factors for these infections vary across the different post-HSCT phases. In the pre-engraftment period, patients are particularly susceptible to infection due to prolonged neutropenia, mucosal damage, and extensive use of central venous line (CVL). In the post-engraftment phase, the emergence of graft versus host diseases further compounds the risk. The epidemiology of these infections has undergone notable changes over the years due to multifactorial reasons, including the evolution of protocols that intensify immunosuppression. In this context, the emergence of multi-drug resistance (MDR) microorganisms can be a challenge due to the elevated risk of mortality in these vulnerable patients. Unfortunately, there is a lack of comprehensive data on this topic, particularly in pediatrics. This article aims to provide a summary of the epidemiology of BSI in the different post-transplant phases and the impact of MDR pathogens. Having knowledge about the local epidemiology of BSI can be instrumental in tailoring targeted therapies, leading to improved survival rates in HSCT recipients.