Outpatient management of pediatric oncology patients with low-risk fever and neutropenia: Implementation of new clinical practice guideline at Texas Children's Hospital.

Abstract

26 Background: Traditionally, pediatric oncology patients with fever and severe neutropenia (absolute neutrophil count [ANC] <500) are admitted on empiric intravenous (IV) antibiotics pending blood cultures, fever resolution, and a rising ANC. Based on significant evidence that risk-stratification of these patients with fever and neutropenia (FN) and outpatient management of “low-risk” FN (LRFN) patients with oral antibiotics can be safe and effective, we implemented an institutional clinical practice guideline (CPG) to provide outpatient care for children with LRFN. Methods: A validated “Alexander” clinical decision rule was adopted to risk stratify pediatric oncology patients with FN. A new CPG was formulated for the outpatient management of LRFN patients, with either discharge on presentation or at 24-48 hours after admission, with levofloxacin and close follow-up. All stakeholders were educated regarding the new guidelines and process prior to implementation, and the guidelines were approved by the institutional Evidence Based Outcomes Center. Results: In 9 months since guideline implementation, 10/11 (91%) of the eligible patients have been managed outpatient for LRFN (mean ANC 160, range 0 - 480). Seven patients were discharged home from the ER or oncology clinic. Three patients were discharged early at 24 – 48 hours after admission. Outpatient management was safe, and all but one patient had resolution of fever within 48 hours and negative blood cultures. One patient had a positive blood culture with Staphylococcus epidermidis and was admitted for IV antibiotics with no complications. Parents of 9/10 patients responded to surveys. All 9 families found outpatient management to be a good experience, follow-up easy, and reported no adverse effects with levofloxacin. One family preferred inpatient care due to anxiety, while importantly 8/9 (89%) parents said they preferred outpatient care compared to inpatient observation. Conclusions: Pediatric oncology patients with low-risk fever and neutropenia were successfully idenitified and managed in the outpatient setting without adverse events with a high level of parent satisfaction.