Burden of Chemotherapy Induced Febrile Neutropenia in Paediatric Oncology in a Low-Income Country: The Children's Hospital Lahore Pakistan Experience

Abstract

Background: Febrile neutropenia (FN) is one of most common and potentially lethal complications in patients with cancer during chemotherapy. The Oncology Department of the Children's Hospital Lahore Pakistan is a 60 bedded unit providing free treatment to over 1300 new childhood cancer cases each year and over 200 admissions per month with bed occupancy rate around 200%. The department receives childhood cancer cases not only from Pakistan but also from Afghanistan. Therefore it's very challenging to treat cancer and infection parallel with increased burden on the public sector hospital providing free treatment as well as on health professionals managing these patients with advanced stages and frequent infection episodes. Aim: The objective of this study is to evaluate the burden of FN in resource limited settings like a public sector hospital in Pakistan. A prospective review of data of patients treated for febrile neutropenia from October to December 2017 in the Haematology/Oncology Department of The Children's Hospital Lahore after IRB approval. The data were analyzed by using SPSS 20. Results: 250 patients were treated for FN during these three months 59% of them male and mean age 6.27 years. Among diagnoses, 58% had acute lymphoblastic leukaemia, 16% sarcomas, 10% lymphoma and 16% other solid malignancies on different chemotherapy regimens. 53% received their chemo during last 3 days and 35% in the last week prior to FN admission. 84% of them were receiving either induction or intensive phase protocols. 48% had respiratory tract infection followed by AGE 25%, fever alone in 20%, 82% cases had mucositis. 52% cases had symptoms of more than 24 hours before seek treatment of FN. ANC (absolute neutrophil count) was < 100 in 60% and platelets < 50,000 in 56% cases on arrival. 57% cases stayed 1-3 hours drive from the Children´s hospital and only 44% parents had adequate awareness of FN management. Regarding the outcome 81% discharged home, 16% expired (mainly FN and progressive disease) and 3% abandoned treatment. G-CSF (granulocyte-colony stimulating factor) was used in 30% (0.026 for RX cost and 0.043 hospital stay) and blood products in 75%, inotropes used in 16% with mean estimated cost of 15,000 RS/patient (total 3.8 million RS) with 95% staying > 48 hrs. 61 cultures were positive mainly urine, blood, ENT, wound, CSF. 92% were Gram negative with majority Klebsiella followed by Pseudomonas, E. coli and Citrobacter species. There were no central lines used. Conclusion: This study described that FN has been a profound burden in childhood cancer care in public sector hospital in resource limited settings like Pakistan. There is immense need to health educate the parents, nurses and doctors for standard care of febrile neutropenia along with sustainable social support and shared care oncology as being provided in developed countries to share the load of primary treatment centers aiming for decreased morbidity and mortality.