Fast antibiotics reduce PICU needs, mortality of pediatric cancer patients

February 27, 2015

Pediatric cancer patients who receive antibiotics within 60 minutes of reporting fever and showing neutropenia (low neutrophil count), go on to have decreased intensive care needs and lower mortality compared with patients who receive antibiotics outside the 60-minute window, according to a University of Colorado Cancer Center study published in Pediatric Blood & Cancer.

Pediatric cancer patients who receive antibiotics within 60 minutes of reporting fever and showing neutropenia (low neutrophil count), go on to have decreased intensive care needs and lower mortality compared with patients who receive antibiotics outside the 60-minute window, according to a University of Colorado Cancer Center study published in Pediatric Blood & Cancer.

In a sample of 220 children, mortality was 3.9% for patients who received antibiotics outside 60 minutes and only 0.7% for those who received antibiotics within the hour.

The study took place within efforts of Children’s Hospital Colorado to improve time-to-delivery of antibiotics in cases of fever and low white blood cell count in pediatric cancer patients, which at study outset required an average 150 minutes. The study describes procedural changes including prescribing antibiotics upon a pediatric cancer patient’s arrival to the hospital, holding that order, then allowing the delivery of antibiotics to start immediately after learning the results of neutrophil count testing (eliminating the need to find a prescriber once the white blood cell count was known).

Related:Antibiotic use increases worldwide

“It is possible to deliver antibiotics to childhood cancer patients with fever within an hour, even when waiting for Absolute Neutrophil Count [ANC] results,” Joanne Hilden, MD, investigator at the CU Cancer Center, director of clinical services for pediatric oncology at Children’s Hospital Colorado, and the study’s senior author, told FormularyWatch.

“In this way you do not give un-necessary antibiotics [ie, to those children who do not have low ANC], you decrease mortality, this is a trend result, had not reached statistical significance, and you decrease the need for intensive care consultation,” Dr Hilden said. “Most places cannot do this in a timely fashion so to meet the time standard, they give antibiotics to all such patients with fever, without waiting for the ANC result.”

When selecting a hospital of choice for children with cancer, the question should be asked: Can you deliver antibiotics to neutropenic patients within the 1 hour national standard, not just giving antibiotics to all?, according to Dr Hilden. “Giving unnecessary antibiotics results in bacterial resistance. Not getting within the hour increases mortality, and cost of care [PICU cost].”

Another intervention describes speeding the time needed to determine the neutrophil count. Traditionally, determining neutropenia requires a full white blood cell count followed by “differential” (counting the percent neutrophils) by a human technician. But human verification reverses the preliminary, machine results in less than 0.5% of cases. Analysis showed that the benefit of speed outweighed the risk of administering unneeded antibiotics in these very few cases. Depending on preliminary rather than technician-verified results of white cell counts reduced the time of testing from 45 minutes to 20.

Related:Antibiotic-resistant bacteria on rise among US children

Taken together, along with changes to clinic flow procedures that included notifying the full care team as soon as the family is advised to come into the hospital and a STAT intake, Children’s Hospital Colorado was able to reduce its time to delivery of antibiotics to a median 46 minutes, with nearly 100% of pediatric patients with fever and neutropenia receiving antibiotics within 60 minutes.