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Grandjean-Blanchet C, Le CK, Villeneuve S, Cada M, Beck CE, Science M, Rosenfield D, Ostrow O. Value-Based Care for Healthy Children With First Episode of Febrile Neutropenia. Hosp Pediatr 2023; 13:536-544. [PMID: 37194483 DOI: 10.1542/hpeds.2022-007075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVES There is a lack of guidance on the management of febrile neutropenia in otherwise healthy children, including the need for hospitalization and antibiotic administration, leading to significant practice variation in management. The aim of this initiative was to decrease the number of unnecessary hospitalizations and empirical antibiotics prescribed by 50% over a 24-month period for well-appearing, previously healthy patients older than 6 months presenting to the emergency department with a first episode of febrile neutropenia. METHODS A multidisciplinary team of stakeholders was assembled to develop a multipronged intervention strategy using the Model for Improvement. A guideline for the management of healthy children with febrile neutropenia was created, coupled with education, targeted audit and feedback, and reminders. Statistical control process methods were used to analyze the primary outcome of the percentage of low-risk patients receiving empirical antibiotics and/or hospitalization. Balancing measures included missed serious bacterial infection, emergency department (ED) return visit, and a new hematologic diagnosis. RESULTS Over the 44-month study period, the mean percentage of low-risk patients hospitalized and/or who received antibiotics decreased from 73.3% to 12.9%. Importantly, there were no missed serious bacterial infections, no new hematologic diagnoses after ED discharge, and only 2 ED return visits within 72 hours without adverse outcomes. CONCLUSIONS A guideline for the standardized management of febrile neutropenia in low-risk patients increases value-based care through reduced hospitalizations and antibiotics. Education, targeted audit and feedback, and reminders supported sustainability of these improvements.
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Affiliation(s)
| | | | | | | | | | - Michelle Science
- Infectious Diseases, The Hospital for Sick Children, Montreal, Canada
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2
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Nguyen SN, Vu LT, Vu QV, Tran TT, Dinh VTT. Clinical Epidemiology Characteristics and Etiology of Febrile Neutropenia in Children: Analysis of 421 Cases. Hematol Rep 2022; 14:245-252. [PMID: 35997401 PMCID: PMC9397012 DOI: 10.3390/hematolrep14030034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/22/2022] [Accepted: 07/19/2022] [Indexed: 01/11/2023] Open
Abstract
The congenital immune system includes neutrophils, which perform a variety of functions. Congenital and acquired neutropenia are rare illnesses with an underestimated prevalence in children. The aim of this study is to examine the epidemiology and etiology of febrile neutropenia in children at Haiphong Children’s Hospital, Haiphong, Vietnam. Methods: A cross-sectional study was carried out on 421 febrile neutropenia children. Clinical and laboratory characteristics were examined. Results: The median age (IQR) was 25.0 (12.5–59.5) months. The male-to-female ratio was 1.35/1. There were twice as many children living in the suburbs (66.98%) as in urban areas (33.02%). The mean (SD) temperature at admission was 38.50 ± 0.59 °C. Diagnosed causes associated with neutropenia included acute respiratory infections 250 (59.45%), gastrointestinal infections 68 (16.1%), erythema 37 (8.79%), acute leukemia 15 (3.56%), urinary tract infection 5 (1.19%), and encephalitis/meningitis 4 (0.95%). Viral etiology accounted for 61.52% (259): influenza type A—50.19% (130), influenza type B—31.27% (81), dengue virus—14.67% (38), measles virus 1—93% (5), rotavirus—1.54% (4), and EBV—0.4% (1). Twenty-five patients (5.94%) were found to have bacteria in their cultures, with Streptococcus pneumonia being the most common (eight patients; 32%). Conclusions: Febrile neutropenia was common in children under 2 years old. Primary clinical manifestations were acute upper respiratory tract infections, and viruses most commonly caused febrile neutropenia. Further studies with larger sample sizes are needed to determine the cause of febrile neutropenia.
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3
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Mora-Capín A, Lorente-Romero J, Hernanz-Lobo A, Rivas-García A, Vázquez-López P, Carrascosa-García P, González-Hermosa A, Mena-Huarte J, Pérez-Saez MA, Nadal G, García-de-Diego I, Marañón-Pardillo R. Risk Factors of Serious Bacterial Infection in Previously Healthy Children Older Than 90 Days Old With Fever and Neutropenia. Pediatr Emerg Care 2022; 38:e1378-e1383. [PMID: 35766931 DOI: 10.1097/pec.0000000000002758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The main objective was to determine the clinical or analytical factors that independently predict risk of serious bacterial infection (RSBI) in immunocompetent patients older than 90 days given a diagnosis of fever and for whom neutropenia was an incidental finding. The secondary objective was to describe the prevalence of serious bacterial infections (SBIs). METHODS This is a 3-year-long, multicenter, prospective analytical and observational study carried out at 6 pediatric emergency departments. Data for epidemiological, clinical, and analytical variables were collected. RESULTS One hundred forty patients with febrile neutropenia (60.7% mild, 39.3% moderate to severe) were recruited. Serious bacterial infection incidence was 15.0% (95% confidence interval [CI], 9-21): 1 Invasive Bacterial Infection (Staphylococcus epidermidis bacteremia), 10 urinary tract infections, 8 pneumonias, and 2 cellulitis. Median total neutrophil counts per microliter showed no statistically significant differences (P = 0.512; 1000 [750-1200] in SBI patients vs 1100 [800-1300] in non-SBI patients). Higher RSBI was observed in patients with neutrophils less than 20% relative to total leukocytes (SBI, 15, 26.3%) than in those with neutrophils of 20% or greater (SBI, 6, 7.2%) (odds ratio, 4.6; 95% CI, 1.7-12.7). In patients with greater than 5000 leukocytes/μL, a percentage of neutrophils less than 20% was related to a greater RSBI with a trend toward statistical significance (odds ratio, 6.1; 95% CI, 0.7-51.1; P = 0.066). The clinical variables did not show a significant association with RSBI. CONCLUSIONS None of the clinical or analytical variables assessed were associated with the RSBI. However, according to a post hoc analysis, in patients with greater than 5000 leukocytes/μL, a neutrophil percentage less than 20% could be an independent risk factor for SBI. A thorough physical examination and basic diagnostic tests (urinalysis and chest x-ray) may help to establish a diagnosis of SBI in the vast majority of cases.
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Affiliation(s)
- Andrea Mora-Capín
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | - Jorge Lorente-Romero
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | - Alicia Hernanz-Lobo
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | - Arístides Rivas-García
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | - Paula Vázquez-López
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | - Paula Carrascosa-García
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
| | | | | | | | | | | | - Rafael Marañón-Pardillo
- From the Hospital Gregorio Marañón, IisGM (Health Research Institute Gregorio Marañón), Madrid
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4
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Arslantaş E, Ayçiçek A, Türkoğlu R, Tahtakesen TN, Uysalol EP, Bayram C, Akici F, Şanlı K, Özdemir N. Clinical Picture, Outcome, and Risk of Serious Bacterial Infections in Immunocompetent Previously Healthy Neutropenic Children. J PEDIAT INF DIS-GER 2021. [DOI: 10.1055/s-0041-1726869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Objective In childhood, the cause of neutropenia is a challenging diagnosis with a spectrum of underlying etiologies. This study was performed to investigate the clinical picture and the outcomes associated with the new onset neutropenia in previously healthy children, and to determine the risk of serious bacterial infection (SBI) in those patients.
Methods Patients presenting between January 2018 and September 2018 with an absolute neutrophil count (ANC) <1,500/μL were retrospectively evaluated. Patients with known underlying chronic disease or immunosuppressive conditions were excluded. Neutropenia was categorized into three groups: mild, 1,000–1,500/μL; moderate, 500 to <1,000/μL; and severe <500/μL.
Results A total of 423 patients were investigated. There were 156 (36.9%), 193 (45.6%), and 74 (17.5%) patients in the mild, moderate, and severe groups, respectively. Bacteremia was detected in one (0.02%) patient and SBI in 21 (4.9%) patients. No significant correlation was found between the incidence of SBI and bacterial infection rate among different age groups (p > 0.05). The incidence of SBI varied significantly according to the severity of the neutropenia (p = 0.012) and as the neutropenia became more severe, the incidence of SBI increased (p = 0.015).
Conclusion The clinical outcome of neutropenia in previously healthy and immunocompetent children is generally good with a relatively low incidence of SBI. We suggest that aggressive therapy and frequent follow-up should be reserved for previously healthy neutropenic children with SBI.
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Affiliation(s)
- Esra Arslantaş
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Ali Ayçiçek
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Recep Türkoğlu
- Department of Pediatrics, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Tuba Nur Tahtakesen
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Ezgi Paslı Uysalol
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Bayram
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Ferhan Akici
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Kamuran Şanlı
- Department of Microbiology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Nihal Özdemir
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
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5
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Tschernin D, Fruchtman Y, Sergienko R, David O, Leibovitz R, Mazar J, Leibovitz E. The etiologic, microbiologic, clinical and outcome characteristics of immunocompetent young children <2 years of age hospitalized with acute neutropenia. Pediatr Neonatol 2021; 62:26-35. [PMID: 32847741 PMCID: PMC7419265 DOI: 10.1016/j.pedneo.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/20/2020] [Accepted: 08/05/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To describe the etiologic, microbiologic, clinical and outcome characteristics of acute neutropenia (absolute neutrophil count, ANC, <1.5 × 109/L) in hospitalized immunocompetent children. METHODS Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, alveolar pneumonia, Brucellosis and Rickettsiosis. RESULTS 431/671 (64.2%) healthy infants and children hospitalized with acute neutropenia were <2 years of age; 176 (40.8%), 167 (38.8%) and 88 (20.4%) patients were aged 0-3, 4-12 and 13-24 months, respectively. There were 19 (4.4%), 53 (12.3%), 140 (32.5%) and 209 (50.8%) patients with ANC count <200, 200-500, 501-1000 and 1001-1500 × 109 cells/L, respectively. Severe neutropenia (<500 × 109/L) was recorded in 72 (16.7%) patients. Fever >38 °C was present in 208/431 (48.3%) patients. Blood cultures were positive in 10 (2.3%), with Brucella melitensis, Staphylococcus aureus and Enterobacter spp. identified in 4, 3 and 2 patients, respectively; 5/10 patients with positive blood cultures were <3 months of age. Overall, 55/431 (12.7%) and 65/431 (15.1%) patients were diagnosed with SBIs and bacterial infections, respectively. Nasal washings-PCR for respiratory viruses was positive in 139/293 (47.4%) patients tested. An infectious etiology (bacterial and/or viral) was diagnosed in 190/431 (44.1%) patients. Three patients were diagnosed with acute lymphocytic leukemia. Resolution of neutropenia was achieved in 111/208 (53.4%) evaluable patients (63%, 50.6% and 48% of patients aged 0-3, 4-12 and >12 months, respectively and 56.8%, 53.5% and 52% of patients with severe, moderate and mild neutropenia, respectively). CONCLUSION Acute neutropenia is common in immunocompetent children <2 years of age and is frequently associated with viral infections. We showed a substantial involvement of bacterial infections and particularly SBIs in the etiology of acute neutropenia. After a 1-month follow-up, resolution of neutropenia occurred in half of the patients, without association with age subgroups and with neutropenia severity.
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Affiliation(s)
- Dov Tschernin
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Yariv Fruchtman
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Ruslan Sergienko
- Department of Public Health, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Odeya David
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Ron Leibovitz
- Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Julia Mazar
- Laboratory of Hematology, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Eugene Leibovitz
- Division of Pediatrics, Ben-Gurion University, Israel; Soroka University Medical Center, Ben-Gurion University, Israel; Faculty of Health Sciences, Ben-Gurion University, Israel.
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6
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Leibovitz E, Kapelushnik J, Alsanaa S, Tschernin D, Sergienko R, Leibovitz R, Mazar J, Fruchtman Y. Comparison of the etiologic, microbiologic, clinical and outcome characteristics of febrile vs. non-febrile neutropenia in hospitalized immunocompetent children. Eur J Clin Microbiol Infect Dis 2020; 39:2415-2426. [PMID: 32720090 PMCID: PMC7384562 DOI: 10.1007/s10096-020-03938-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/01/2020] [Indexed: 11/30/2022]
Abstract
We compared the etiologic, microbiologic, clinical, and outcome picture among febrile and non-febrile immunocompetent children hospitalized during 2013–2015 with acute neutropenia (absolute neutrophil count < 1.5 × 109/L). Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, pneumonia, brucellosis, and rickettsiosis. Overall, 664 children < 18 years of age were enrolled; 407 (62.2%) had fever > 38.0 °C and 247 (37.8%) were non-febrile at admission. There were 425 (64.0%), 125 (18.8%), 48 (7.2%), and 66 (9.9%) patients aged 0–24 months, 2-6, 7–12, and > 12 years, respectively. No differences were recorded in the distribution of febrile vs. non-febrile patients among the age groups nor among the 3 neutropenia severity groups (< 0.5, 0.5–1.0 and 1.0–1.5 × 109/L). SBI infections were diagnosed in 98 (14.8%) patients, with higher rates among febrile patients vs. non-febrile patients (16.8% vs. 11.5%, P = 0.06). Brucellosis and rickettsiosis were diagnosed in 15.4% and 23.1% tests performed, respectively. 295/688 (42.9%) virologic examinations returned positive. Among patients < 24 months, more febrile ones had viral infectious compared with afebrile patients (P = 0.025). Acute leukemia was diagnosed in 6 patients. Neutropenia resolved in 163/323 (50.5%) patients during a 1-month follow-up. No differences were recorded in neutropenia resolution between febrile and non-febrile children among all 3 severity groups. Severe neutropenia was rare and occurred mainly in very young patients. SBIs were more common among febrile patients compared with non-febrile patients, but there was no association between severity of neutropenia or its resolution and the presence or absence of fever at diagnosis.
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Affiliation(s)
- Eugene Leibovitz
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel. .,Soroka University Medical Center, Beer Sheva, Israel. .,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel. .,Pediatric Infectious Disease Unit, Soroka University Medical Center, P.O. Box 151, 84101, Beer Sheva, Israel.
| | - Joseph Kapelushnik
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Sabrin Alsanaa
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Dov Tschernin
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Ruslan Sergienko
- Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel.,Epidemiology Department, Soroka University Medical Center, Beer Sheva, Israel
| | - Ron Leibovitz
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Julia Mazar
- Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel.,Laboratory of Hematology, Soroka University Medical Center, Beer Sheva, Israel
| | - Yariv Fruchtman
- Division of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
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7
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Solis K, Dehority W. Antibiotic-Induced Neutropenia During Treatment of Hematogenous Osteoarticular Infections in Otherwise Healthy Children. J Pediatr Pharmacol Ther 2019; 24:431-437. [PMID: 31598107 DOI: 10.5863/1551-6776-24.5.431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We studied the frequency and characteristics of antibiotic-induced neutropenia in otherwise healthy children receiving antibiotic therapy for hematogenous osteoarticular infections (OAIs). METHODS We retrospectively enrolled otherwise healthy children between 1 month and 18 years of age discharged with an OAI from our institution over an 11-year period. An absolute neutrophil count (ANC) ≤1500 cells/μL was defined as neutropenia. We recorded demographic and clinical information, as well as the value and timing of each ANC in relation to changes in antibiotic therapy. A multivariable regression model assessed the contributions of various risk factors. RESULTS A total of 186 children were enrolled (mean age, 7.6 years; 67.2% boys). β-Lactams represented 61.2% of all prescriptions. During treatment, 61 subjects (32.8%) developed neutropenia (median time to onset, 24 days). An ANC < 500 cells/μL occurred in 7 subjects (3.8%). Neutropenic subjects (mean age, 6.0 years) were significantly younger than those without neutropenia (mean age, 8.5 years) (OR = 0.86; 95% CI: 0.79-0.93; p < 0.001) and received significantly longer courses of total (89.3 vs. 55.8 days) and parenteral (24.6 vs. 19.9 days) antibiotic therapy (OR = 1.01; 95% CI: 1.01-1.02; p = 0.004 and OR = 1.02; 95% CI: 1.01-1.04; p = 0.041, respectively). Recurrent neutropenia occurred in 23.0% of all neutropenic subjects and was significantly more common in those with a longer mean duration of parenteral therapy (OR = 1.05; 95% CI: 1.02-1.09; p = 0.004.). No complications from neutropenia occurred. CONCLUSIONS Neutropenia was common in our cohort of children receiving prolonged antibiotic therapy for OAIs. Younger age and longer courses of therapy were associated with an increased risk of neutropenia.
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8
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Higgins P, Runnegar N, Bird RJ, Markey KA. Rates of neutropenia in adults with influenza A or B: a retrospective analysis of hospitalised patients in South East Queensland during 2015. Intern Med J 2017; 46:1328-1332. [PMID: 27813353 DOI: 10.1111/imj.13239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 10/20/2022]
Abstract
Neutropenia in adult patients is often attributed to intercurrent viral infections; however, there are limited data describing the frequency or natural history of this phenomenon. We examined all patients presenting to three large hospitals in the Metro South region of South East Queensland with laboratory-confirmed influenza A or B throughout the 2015 influenza season (January-October). Four hundred and thirty-six patients were studied and 15.3% of this cohort were neutropenic (absolute neutrophil count <2.0 × 109 /L) with no identifiable cause other than the influenza. Importantly, the majority of cases were mild, with absolute neutrophil count remaining >1.0 × 109 /L. The incidence of neutropenia was significantly higher in association with influenza B than influenza A (18.3% vs 10.3%). We conclude that mild, transient neutropenia is common among patients with influenza infection and advise that it should not cause alarm or invite specific investigation unless severe or prolonged.
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Affiliation(s)
- P Higgins
- Haematology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - N Runnegar
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - R J Bird
- Haematology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - K A Markey
- Haematology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia. .,Department of Immunology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia. .,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
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9
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Pascual C, Trenchs V, Hernández-Bou S, Català A, Valls AF, Luaces C. Outcomes and infectious etiologies of febrile neutropenia in non-immunocompromised children who present in an emergency department. Eur J Clin Microbiol Infect Dis 2016; 35:1667-72. [PMID: 27319003 DOI: 10.1007/s10096-016-2708-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 06/06/2016] [Indexed: 12/27/2022]
Abstract
There are no unified protocols governing the management of healthy children with febrile neutropenia in the emergency department (ED). Conservative management is the norm, with admission and empirical broad-spectrum antibiotics prescribed, although viral infections are considered the most frequent etiology. The aim of this study was to describe the clinical outcomes and identified etiologies of unsuspected neutropenia in febrile immunocompetent children assessed in the ED. This was a retrospective study: well-appearing healthy children <18 years old with febrile moderate [absolute neutrophil count (ANC) 500-999 neutrophils ×10(9)/l] or severe (ANC <500 neutrophils ×10(9)/l) neutropenia diagnosed in ED between 2005 and 2013 were included. Patients newly diagnosed with hematologic or oncologic disease were excluded. We included 190 patients: 158 (83.2 %) with moderate and 32(16.8 %) with severe neutropenia. One hundred and one (53.2 %) were admitted; 48(47.5 %) with broad-spectrum antibiotics. The median length of stay was 3 days (IQR 3-5) and the median duration of neutropenia was 6 days (IQR 3-12). An infectious agent was identified in 23(12.1 %); 21 (91.3 %) were viruses. Four (2.1 %) children had a serious bacterial infection (SBI): urinary tract infection and lobar pneumonia (two cases each). All blood cultures performed (144; 75.8 %) were negative. Over the 1-year follow-up, one or several blood tests were performed on 167 patients (87.9 %); two (1.2 %) were diagnosed with autoimmune chronic neutropenia. Previously healthy children with moderate or severe febrile neutropenia have a low risk of SBI and a favorable clinical outcome. Less aggressive management could be carried out in most of them. Although chronic hematological diseases are infrequently diagnosed, serial ANC are necessary to detect them.
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Affiliation(s)
- C Pascual
- Pediatric Emergency Department, Hospital Sant Joan de Déu Barcelona, Passeig Sant Joan de Déu 2, 08940, Esplugues de Llobregat, Barcelona, Spain
| | - V Trenchs
- Pediatric Emergency Department, Hospital Sant Joan de Déu Barcelona, Passeig Sant Joan de Déu 2, 08940, Esplugues de Llobregat, Barcelona, Spain
| | - S Hernández-Bou
- Pediatric Emergency Department, Hospital Sant Joan de Déu Barcelona, Passeig Sant Joan de Déu 2, 08940, Esplugues de Llobregat, Barcelona, Spain.
| | - A Català
- Department of Pediatric Hematology & Oncology, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - A F Valls
- Laboratory Department, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - C Luaces
- Pediatric Emergency Department, Hospital Sant Joan de Déu Barcelona, Passeig Sant Joan de Déu 2, 08940, Esplugues de Llobregat, Barcelona, Spain
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10
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Affiliation(s)
- Katie Knight
- Department of Paediatrics, Homerton University Hospital, London, UK
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11
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Abstract
Only few reports have looked into the risk of invasive bacterial infection in children with neutropenia that is not malignancy related. The objective of the current study was to determine the clinical significance of neutropenia as a predictor of serious bacterial infection (SBI) in immunocompetent children. We conducted a retrospective case-control study including children 3 months to 18 years of age with fever ≥ 38°C hospitalized or presenting to the emergency department. Patients who had neutropenia ≤ 1000 ANC/μL and had a blood culture taken were matched for age with the consecutive febrile patients for whom a blood culture was taken. The main outcome was the rate of SBI. SBIs were more prevalent among the control group than in the group of children with neutropenia, 19/71 and 6/71, respectively (P = 0.0005). More children were treated with antibiotics among the control group than in the group of children with neutropenia, 39/71 and 20/71, respectively (P < 0.0001). Acute-phase reactants including CRP and platelets were higher in the control group. We concluded that immunocompetent patients with fever and moderate neutropenia do not carry a higher risk for SBIs compared with patients with fever who do not have neutropenia.
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12
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Angelino G, Caruso R, D'Argenio P, Calò Carducci FI, Pascone R, Lanciotti M, Cancrini C, Palma P, Aiuti A, Rossi P, Finocchi A. Etiology, clinical outcome, and laboratory features in children with neutropenia: analysis of 104 cases. Pediatr Allergy Immunol 2014; 25:283-9. [PMID: 24325465 DOI: 10.1111/pai.12177] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neutropenia is not uncommon in childhood. The aim of our study was to analyze the underlying causes of neutropenia and to evaluate its clinical significance in a series of children referred to our center. METHODS One hundred and four consecutive children with neutropenia were enrolled in this study. Clinical and laboratory features were analyzed. RESULTS The majority of patients (63.5%) showed chronic neutropenia. Among all chronic forms, the most frequent was chronic idiopathic neutropenia (CIN), followed by autoimmune neutropenia (AIN). Congenital neutropenia was identified in 6 patients. Acute neutropenia was mainly due to infections. Overall, at the time of first detection, neutropenia was more frequently severe or moderate. One-third of our patients who presented with severe neutropenia were ultimately diagnosed with a post-infectious acute form. Conversely, nearly half patients with CIN, AIN, or congenital neutropenia showed moderate/mild neutropenia at onset. Among patients with AIN and CIN, nearly half recovered between 7 months and 46 months and approximately one-fourth experienced infectious episodes during follow-up. No significant difference was noticed in terms of mean ANC between patients with and without remission, neither between patients with and without infections. CONCLUSIONS Our study confirms the great etiological heterogeneity of neutropenia in children. We could not demonstrate a correlation between ANC level at onset and the underlying disorder, nor a correlation between mean ANC and duration of neutropenia or infectious episodes during follow-up. Neutropenia remains a disease of concern to pediatricians, requiring several laboratory investigations, prolonged follow-up, and, in few cases, advanced molecular methods.
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Affiliation(s)
- Giulia Angelino
- University-Hospital Pediatric Department, Bambino Gesù Children's Hospital IRCCS and University of Rome, 'Tor Vergata' School of Medicine, Rome, Italy
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Abstract
BACKGROUND Healthy children presenting with neutropenia are often hospitalized and treated empirically with antibiotics without an evidence of infection. The objective of this study was to investigate the infectious causes of isolated transient neutropenia in otherwise previously healthy children. METHOD A 2-year prospective study was conducted at a tertiary hospital in Kuwait. All previously healthy children (aged 1 month to 12 years) hospitalized with isolated neutropenia defined as absolute neutrophil count (ANC) ≤ 1.5 × 10/L were enrolled in the study. Investigations to identify the infectious causes included blood and urine culture for bacteria whereas for viruses, serology for Epstein-Barr virus, cytomegalovirus, adenovirus, parvovirus and polymerase chain reaction for human herpes virus 6 and enterovirus were performed. RESULTS Fifty-five children were enrolled during the study. Children less than 2 years of age constituted 73% of the sample. There were 2 peaks of presentation: March-May (33%) and September-November (38%). Associated features were congested throat (56%), runny nose (53%) and cervical lymphadenopathy (20%). The median ANC on admission was 0.6 × 10/L. Associated infections were documented in 55% of enrolled children and were as follows: human herpesvirus 6, 30%; enterovirus, 23%; influenza A H1N1, 13%; parvovirus, 10%; Epstein-Barr virus, 10%; urinary tract infection, (Eshcherichia coli) 7%; and adenovirus, 7%. No serious bacterial infection was identified, and the mean time for recovery of the ANC was 16.7 ± 15 days. CONCLUSIONS Neutropenia in previously healthy children in Kuwait is caused by demonstrable infections in 55% of cases. Majority of children will recover their ANC completely within 1 month without significant infectious complications.
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