Fever at diagnosis of pediatric acute lymphoblastic leukemia (ALL): Are antibiotics really necessary?

Abstract

9553 Background: Great variability exists in the management of suspected bacteremia in febrile, neutropenic pediatric ALL patients during chemotherapy. The National Comprehensive Cancer Network and Infectious Diseases Society of America encourage immediate, empiric antibiotics in patients with chemotherapy-induced fever and neutropenia to reduce infection-related mortality. No standard recommendation exists for patients with isolated fever at initial presentation of their ALL. This study evaluates bacteremic episodes in this subpopulation of pediatric patients. Methods: We retrospectively analyzed 245 consecutive patients with ALL at Children’s Hospital Oakland from 2000 through 2011. Using electronic medical records, we investigated each patient’s history and outcome. We surveyed bacteremic episodes up to 60 days after presentation per National Healthcare Safety Network’s guidelines. Inclusion criteria were patients with fever at presentation, which prompts a blood culture, and were started on antibiotics. We stratified bacteremic episodes into community-acquired (up to three days from admission) and nosocomial (four to 60 days). Results: Seventy-seven patients met the inclusion criteria, five of whom had positive cultures – four were contaminants (three coagulase-negative Staphylococcus and one non-anthracis Bacillus) and one was a true nosocomial bactermic episode (E coli). There were no infection-related deaths in the first 60 days of diagnosis in this cohort. Conclusions: Given our institution’s rarity of bacteremic episodes, we contemplate a more judicious use of antibiotics, including quicker narrowing of broad-spectrum antibiotics coverage and discontinuing all antibiotics sooner. These modifications may decrease bacterial resistance to antibiotics, reduce costs, and shorten patients’ hospitalization. We encourage other institutions to conduct a similar investigation.