Determining Discharge Criteria for Pediatric Patients Admitted With Febrile Neutropenia

Management of pediatric oncology patients with febrile neutropenia and hospitalization duration currently vary by institution and by provider.

A poster presented at the 59th American Society of Hematology Annual Meeting reviewed pediatric hematology/oncology patients who were admitted from September 2005 to October 2016 with febrile neutropenia to determine discharge and release, as well as subsequent readmission within the next 4 days.

The common treatment strategy for patients hospitalized with neutropenia is to continue inpatient parenteral antibiotics therapy until myelorecovery is seen. While studies suggest outpatient therapy, oral antibiotics, or earlier discharge could be appropriate in some patients, there is a lack of data supporting such a regimen.

“Current Children’s Oncology Group guidelines recommend considering discontinuing empiric antibiotics at 72 hours in low risk patients with negative blood cultures for at least 24 hours irrespective of marrow recovery,” the authors noted. “However, this is a weak recommendation with only moderate quality evidence.”

The authors ultimately reviewed 729 febrile neutropenia admissions and determined 131 of them were considered “early discharges," meaning they were discharged home at 4 or less days with discharge absolute neutrophil count (ANC) < 500 and negative cultures. All of the patients were afebrile at the time of discharge. Just 11 of the 131 (8%) were readmitted for reasons other than chemotherapy.

The average ANC at discharge was lower for patients who were ultimately readmitted compared with those who were not readmitted (69 vs 198, P ≤.0001) and the mean age of those readmitted was also younger than those not readmitted (4.2 years vs 7 years).

The researchers found no difference regarding gender, type of malignancy, or ANC on admission between the groups of patients readmitted and those not readmitted.

Ultimately, the authors determined that 92% of the early discharge patients were low risk and were safely discharged without incident. Only a small percentage of patients were readmitted for repeat fevers while neutropenic and those with bacterial infections were easily identified and treated. Applying a higher ANC count criteria before discharge would ultimately mean low-risk children stay hospitalized for a longer period of time and the new criteria wouldn’t decrease morbidity.

“This retrospective review showed that low risk patients admitted with febrile neutropenia could be safely discharged prior to count recovery without oral antibiotics,” the authors concluded.