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Smith WT, Read J, Agarwal S, Tian G, Anum SJ, Choe M, Kurtz K, Tlais D, Shen X, Sarro J, Looney T, Porea T, Sauer H, Brackett J, Okcu MF, Chintagumpala M. Improving Time to Antibiotic Administration for Pediatric Oncology Patients With New-Onset Fever. JCO Oncol Pract 2024; 20:725-731. [PMID: 38354362 DOI: 10.1200/op.23.00314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) in <60 minutes for children with neutropenic fever presenting to an emergency room is associated with reduced incidence of sepsis and intensive care admission. As such, TTA is used as a national quality metric for pediatric oncology patients. At our center, in 2020, 19% of the hospitalized patients with a new fever encounter were receiving antibiotics in <60 minutes, prompting a multidisciplinary approach to reach a goal of >90% in all pediatric patients with cancer with a new fever. METHODS A multidisciplinary team completed four Plan-Do-Study-Act cycles between March 2021 and September 2023. We implemented education initiatives, an updated handoff smartphrase guiding the on-call team, an antibiotic champion (AC) nursing role, a revised fever plan for handoff, a rapid-response team to address new fevers, and an algorithm for blood culture collection. Data were collected, analyzed, and reported biweekly with feedback sought for delays in TTA. RESULTS There was a total of 639 new fevers in 329 unique oncology patients. As of September 4, 2023, average TTA decreased from 89 minutes at baseline to 46.4 minutes for more than 12 months. The percentage of patients receiving first dose of antibiotic in <60 minutes also increased from 19% to 93.7%, which was sustained as well. The most effective interventions were creation of the AC role and streamlining the blood culture collection process. CONCLUSION This project demonstrates the importance of multidisciplinary involvement for providing optimal care. Specific implementation of targeted education, an AC role, and development of an algorithm streamlining the processes led to meaningful targeted improvements. Further analyses will explore the impact of these interventions on patient outcomes.
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Affiliation(s)
- Wesley T Smith
- Department of Pediatrics, Division of Hematology/Oncology, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Jay Read
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shreya Agarwal
- Department of Pediatrics, Division of Hematology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Gengwen Tian
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shaniqua J Anum
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Michelle Choe
- Clinical Research Division, Department of Pediatrics, Fred Hutchinson Cancer Center, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kristen Kurtz
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Dana Tlais
- Department of Oncology, Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Xiaofan Shen
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jill Sarro
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Thomas Looney
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy Porea
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Hannah Sauer
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Julienne Brackett
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Murali Chintagumpala
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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De Castro GC, Slatnick LR, Shannon M, Zhao Z, Jackson K, Smith CM, Whitehurst D, Elliott C, Clark CC, Scott HF, Friedman DL, Demedis J, Esbenshade AJ. Impact of Time-to-Antibiotic Delivery in Pediatric Patients With Cancer Presenting With Febrile Neutropenia. JCO Oncol Pract 2024; 20:228-238. [PMID: 38127868 PMCID: PMC10911541 DOI: 10.1200/op.23.00583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Febrile neutropenia (FN) in pediatric patients with cancer can cause severe infections, and prompt antibiotics are warranted. Extrapolated from other populations, a time-to-antibiotic (TTA) metric of <60 minutes after medical center presentation was established, with compliance data factoring into pediatric oncology program national rankings. METHODS All FN episodes occurring at Vanderbilt Children's Hospital (2007-February 2022) and a sample of episodes from Colorado Children's Hospital (2012-2019) were abstracted, capturing TTA and clinical outcomes including major complications (intensive care unit [ICU] admission, vasopressors, intubation, or infection-related mortality). Odds ratios (ORs) were adjusted for age, treatment center, absolute neutrophil count, hypotension presence, stem-cell transplant status, and central line type. RESULTS A total of 2,349 episodes were identified from Vanderbilt (1,920) and Colorado (429). Only 0.6% (n = 14) episodes required immediate ICU management, with a median TTA of 28 minutes (IQR, 20-37). For the remaining patients, the median TTA was 56 minutes (IQR, 37-90), and 54.3% received antibiotics in <60 minutes. There were no significant associations between TTA (<60 or ≥60 minutes) and major complications (adjusted OR, 0.99 [95% CI, 0.62 to 1.59]; P = .98), and a TTA ≥60 minutes was not associated with any type of complication. Similarly, TTA, when evaluated as a continuous variable, was not associated with a major (OR, 0.99 [95% CI, 0.94 to 1.04]; P = .69) nor any other complication in adjusted analysis. CONCLUSION There is no clear evidence that a reduced TTA improves clinical outcomes in pediatric oncology FN and thus it should not be used as a primary quality measure.
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Affiliation(s)
| | - Leonora R. Slatnick
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | | | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Kasey Jackson
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Christine M. Smith
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Claire Elliott
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Chelsea C. Clark
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Halden F. Scott
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Debra L. Friedman
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Jenna Demedis
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Adam J. Esbenshade
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Nessle CN, Njuguna F, Dettinger J, Koima R, Nyamusi L, Kisembe E, Kinja S, Ndung'u M, Njenga D, Langat S, Olbara G, Moyer C, Vik T. Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study. BMJ Open 2023; 13:e078124. [PMID: 37918936 PMCID: PMC10626801 DOI: 10.1136/bmjopen-2023-078124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION Febrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher than in high-resourced treatment settings, thought to be related to delays in antibiotic administration and management. The barriers to effective management of fever episodes in children with cancer have not previously been described. This convergent mixed-methods study will provide the evidence to develop fever treatment guidelines and to inform their effective implementation in children with cancer at Moi Teaching and Referral Hospital (MTRH), a level 6 referral hospital in western Kenya. METHODS AND ANALYSIS Prospective data collection of paediatric patients with cancer with new fever episodes admitted to MTRH will be performed during routine treatment. Clinical variables will be collected from 50 fever episodes, including cancer diagnosis and infectious characteristics of the fever episode, and elapsed time from fever onset to various milestones in the management workflow. Semistructured qualitative interviews with healthcare providers (estimated 20 to reach saturation) will explore the barriers to and facilitators of appropriate management of fever episodes in children with cancer. The interview guide was informed by a theoretical framework and Consolidated Framework for Implementation Research. A mixed-methods analysis use of joint display tables and process mapping will link and integrate the two types of data with meta-inferences. ETHICS AND DISSEMINATION Institutional review board approval was obtained from the MTRH (0004273) and the University of Michigan (HUM0225674), and the study was registered with National Commission for Science Technology and Innovation (P/23/22885). Written consent will be obtained from all participants. Results will be formally shared with local and national policy leadership and local end users, presented at relevant national academic conferences and submitted for publication in a peer-reviewed journal.
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Affiliation(s)
- Charles Nathaniel Nessle
- Department of Pediatrics, Division of Hematology-Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Fogarty International Center, National Institute of Health, Bethesda, Maryland, USA
| | - Festus Njuguna
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Raphael Koima
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Lenah Nyamusi
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Evelynn Kisembe
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- Behavioral and Social Science Research, Moi University, Eldoret, Kenya
| | - Sarah Kinja
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Mercy Ndung'u
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Dennis Njenga
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Sandra Langat
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Gilbert Olbara
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Cheryl Moyer
- Medical School, Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Terry Vik
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
- Department of Pediatrics, Division of Hematology-Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Simon A, Lehrnbecher T, Baltaci Y, Dohna-Schwake C, Groll A, Laws HJ, Potratz J, Hufnagel M, Bochennek K. [Time to Antibiotics (TTA) - Reassessment from the German Working Group for Fever and Neutropenia in Children and Adolescents (DGPI/GPOH)]. KLINISCHE PADIATRIE 2023; 235:331-341. [PMID: 37751768 DOI: 10.1055/a-2135-4210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND The current German guidance from 2016 recommends a Time to Antibiotics (TTA) of<60 min in children and adolescents with febrile neutropenia (FN). METHODS Critical analysis of available studies and recent meta-analyses, and discussion of the practical consequences in the FN working group of the German Societies for Paediatric Oncology and Haematology and Paediatric Infectious Diseases. RESULTS The available evidence does not support a clinically significant outcome benefit of a TTA<60 min in all paediatric patients with FN. Studies suggesting such a benefit are biased (mainly triage bias), use different TTA definitions and display further methodical limitations. In any case, a TTA<60 min remains an essential component of the 1st hour-bundle in paediatric cancer patients with septic shock or sepsis with organ dysfunction. CONCLUSION Provided that all paediatric FN patients receive a structured medical history and physical examination (including vital signs) by experienced and trained medical personnel in a timely fashion, and provided that a sepsis triage and management bundle is established and implemented, a TTA lower than 3 hours is sufficient and reasonable in stable paediatric cancer patients with FN.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Homburg, Homburg, Germany
| | - Thomas Lehrnbecher
- Klinik für Kinder- und Jugendheilkunde, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt, Germany
| | - Yeliz Baltaci
- Pädiatrische Onkologie und Hämatologie, TeleKasper Projekt, Universitätskinderklinik Homburg, Homburg, Germany
| | | | - Andreas Groll
- Päd. Hämatologie und Onkologie, Univ.-Klinikum Münster, Klinik für Kinder- und Jugendmedizin, Münster, Germany
| | - Hans-Jürgen Laws
- Klinik für Kinder-Onkologie, - Hämatologie und - Klinische Immunologie, Universerstitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Jenny Potratz
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Münster, Muenster, Germany
| | - Markus Hufnagel
- Klinik für Kinderheilkunde und Jugendmedizin, Universitätskinderklinik Freiburg, Freiburg, Germany
| | - Konrad Bochennek
- Pädiatrische Hämatologie und Onkologie, Universitätsklinik Frankfurt, Frankfurt, Germany
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Butters C, Thursky K, Hanna DT, Cole T, Davidson A, Buttery J, Haeusler G. Adverse effects of antibiotics in children with cancer: are short-course antibiotics for febrile neutropenia part of the solution? Expert Rev Anti Infect Ther 2023; 21:267-279. [PMID: 36694289 DOI: 10.1080/14787210.2023.2171987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Febrile neutropenia is a common complication experienced by children with cancer or those undergoing hematopoietic stem cell transplantation. Repeated episodes of febrile neutropenia result in cumulative exposure to broad-spectrum antibiotics with potential for a range of serious adverse effects. Short-course antibiotics, even in patients with high-risk febrile neutropenia, may offer a solution. AREAS COVERED This review addresses the known broad effects of antibiotics, highlights developments in understanding the relationship between cancer, antibiotics, and the gut microbiome, and discusses emerging evidence regarding long-term adverse antibiotic effects. The authors consider available evidence to guide the duration of empiric antibiotics in pediatric febrile neutropenia and directions for future research. EXPERT OPINION Broad-spectrum antibiotics are associated with antimicrobial resistance, Clostridioides difficile infection, invasive candidiasis, significant disturbance of the gut microbiome and may seriously impact outcomes in children with cancer or undergoing allogenic hematopoietic stem cell transplant. Short-course empiric antibiotics are likely safe in most children with febrile neutropenia and present a valuable opportunity to reduce the risks of antibiotic exposure.
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Affiliation(s)
- Coen Butters
- Department of General Paediatrics and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Diane T Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Theresa Cole
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Andrew Davidson
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Anaesthesia, Royal Children's Hospital, Parkville, Australia.,Department of Critical Care, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, Australia
| | - Jim Buttery
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Centre for Health Analytics, Melbourne Children's Campus, Parkville, Australia.,Health Informatics Group and SAEFVIC, Murdoch Children's Research Institute, Parkville, Australia
| | - Gabrielle Haeusler
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia
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