Clinical Epidemiology Characteristics and Etiology of Febrile Neutropenia in Children: Analysis of 421 Cases

A scoping review study of patients with a primary immune deficiency who have presented to the paediatric emergency department with a fever

AIM

To identify, analyse, and synthesise existing research on the characteristics and risk factors associated with primary immune deficiencies (PIDs), with focus on understanding how factors impede patient outcomes.

BACKGROUND

There is currently limited research regarding the management of this cohort when they present to an emergency department with the presentation urgency often being overlooked.

METHOD

Three databases, google scholar, and citations were searched for relevant studies under the criteria. Included papers were analysed and reported following the PRISMA guideline, and then critically appraised using the Mixed Method Appraisal Tool.

RESULTS

After a review of 625 titles and abstracts, 20 studies met the inclusion criteria. The majority being mixed method (n = 8) and case studies (n = 8). All chosen studies reported some form of management of a child with a PID, and most made recommendations for improvement.

CONCLUSIONS

Further research is needed to facilitate an understanding of how to enhance emergency management, to increase positive outcomes.

RELEVANCE TO PRACTICE

There is a critical need for improved management strategies for children with a PID presenting to ED with fever. Creating protocols, increasing staff knowledge, and implementing patient specific interventions are essential in improving outcomes and reducing serious complications in this high-risk paediatric population.

Febrile illness in high-risk children: a prospective, international observational study

To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the 'Biomarker Validation in HR patients' database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1-4.6)) and HIV (OR 10.4 (95% CI 2.0-54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3-0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522).   Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population. What is Known: • Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom. • Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low. What is New: • Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective. • The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.