Cost‐effectiveness of home‐based care of febrile neutropenia in children with cancer

Tew, Michelle; Lourenço, Richard De Abreu; Gordon, Joshua; Thursky, Karin; Slavin, Monica; Babl, Franz; Orme, Lisa; Bryant, Penelope A; Teh, Benjamin W; Dalziel, Kim; Haeusler, Gabrielle M

doi:10.1002/pbc.29469

Cited by 11 publications

(10 citation statements)

References 33 publications

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“…In children with FN, a comprehensive care pathway, which included the Swiss Pediatric Oncology Group (SPOG) CDR (despite an AUC of 0.54 in prospective validation cohort) as well as additional home‐based care criteria, resulted in the safe and successful early hospital discharge of 22% of FN presentations over an 18‐month period 15 . The programme significantly reduced hospital LOS and was more effective and less costly than traditional in‐hospital management 16 . Similarly, in children with NNF, implementation of the EsVan rule led to a reduction in unnecessary antibiotics, with over 70% of all episodes never requiring intravenous antibiotics 7 .…”

Section: Discussionmentioning

confidence: 99%

“…15 The programme significantly reduced hospital LOS and was more effective and less costly than traditional in-hospital management. 16 Similarly, in children with NNF, implementation of the EsVan rule led to a reduction in unnecessary antibiotics, with over 70% of all episodes never requiring intravenous antibiotics. 7 This NNF care pathway specified that children with low BSI risk (<10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (>40%) be admitted on broad-spectrum antibiotics.…”

Section: Microbiologically Defined Infection (Excluding Bacteraemia) ...mentioning

confidence: 99%

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Non‐neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation

Walker

Esbenshade

Dale

et al. 2022

Pediatric Blood & Cancer

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Introduction Fever and infection are an important complication of childhood cancer therapy. Most research and guideline development has focussed on febrile neutropenia, with a paucity directed at non‐neutropenic fever (NNF). We describe the clinical presentation, management and outcomes of NNF in children with cancer, and externally validate the Esbenshade Vanderbilt (EsVan) clinical decision rules (CDR) to predict bacteraemia. Method Using a prospective database, retrospective data were collected on consecutive NNF episodes (fever ≥38.0°C and absolute neutrophil count >1.0 cells/mm3). Sensitivity, specificity and area under the receiver operator characteristic curve (AUC‐ROC) of the CDR were compared to derivation study. Results There were 203 NNF episodes occurring in 125 patients. Severe sepsis was uncommon (n = 2, 1%) and bacteraemia occurred in 10 (4.9%, 95% confidence interval [CI]: 2.7%–8.8%) episodes. A confirmed or presumed bacterial infection requiring antibiotics occurred in 31 (15%) patients. Total 202 (99%) episodes received at least one dose of intravenous broad‐spectrum antibiotic and 141 (70%) episodes were admitted to hospital. Six (3%) episodes required intensive care unit (ICU)‐level care and there were no infection‐related deaths. The EsVan 1 rule had an AUC‐ROC of 0.67, 80% were identified as low risk, and sensitivity and specificity were 50% and 81.5%, respectively, for a risk threshold of 10%. Conclusions Serious infection and adverse outcome are uncommon in children with NNF. Many children did not have a bacterial cause of infection identified, but were still treated with broad‐spectrum antibiotics and admitted to hospital. National clinical practice guidelines should be developed for this important cohort to enable risk stratification and optimise antibiotic management. Further research is required to determine appropriateness of EsVan CDR in our cohort.

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Section: Discussionmentioning

confidence: 99%

Section: Microbiologically Defined Infection (Excluding Bacteraemia) ...mentioning

confidence: 99%

Non‐neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation

Walker

Esbenshade

Dale

et al. 2022

Pediatric Blood & Cancer

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“…There are limited contemporary data on patterns of antibiotic exposure in the pediatric immunocompromised patient setting and the factors, including reasons for initiation and types of infection, that may drive use. In the Australian Predicting Infectious Complications in Children with Cancer (PICNICC) study, the median duration of antibiotics in children with high‐risk febrile neutropenia was 12 days and 13% had a BSI 11–13 . However, this study excluded patients who had undergone allo‐HCT within the preceding 3 months.…”

Section: Introductionmentioning

confidence: 99%

Density of antibiotic use and infectious complications in pediatric allogeneic hematopoietic cell transplantation

Andrew

Khaw

Hanna

et al. 2023

Transplant Infectious Dis

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Background Antibiotics, while an essential component of supportive care in allogeneic hematopoietic cell transplantation (allo‐HCT), can have adverse effects and select for antibiotic resistance. Understanding of patterns of use will inform antimicrobial stewardship (AMS) interventions. Methods Retrospective, single‐center cohort of children undergoing first allo‐HCT (n = 125). Antibiotic prescription and infection data were included from the date conditioning was commenced until 30 days post allo‐HCT. Antibiotic use was reported as length of therapy (LOT) (number of days a patient received an antibiotic) and days of therapy DOT (aggregating all antibiotics prescribed per day). Infections were classified as microbiologically documented infection (MDI) or clinically documented infections. Results At least one course of antibiotics was administered to 124 (99%) patients. The LOT was 636 per 1000 patient days and DOT was 959 per 1000 patient days. The median duration of cumulative antibiotic exposure per patient was 24 days (interquartile range [IQR] 20–30 days). There were 131 days of fever per 1000 patient days with patients febrile for a median of 4 days (IQR 1–7 days). Piperacillin–tazobactam was used for 116 (94%) of patients with an LOT of 532 per 1000 patient days. A total of 119 MDI episodes occurred in 74 (59%) patients, including blood stream infection in 30 (24%) and a proven/probable invasive fungal infection in 4 (3%). Conclusion Pediatric HCT patients receive prolonged courses of broad‐spectrum antibiotics relative to the frequency of fever and bacterial infections. This study has identified opportunities for AMS intervention to improve outcomes for our HCT patients.

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“…Combined with an associated management pathway including homecare criteria, it was piloted in Melbourne Australia using an ambulatory intravenous antibiotic regimen 5. The programme was safe, resulted in significant reduction in bed occupancy and up to $A12 000 lower healthcare costs per patient 6. The CCLG guidance was based on this programme, but used an oral antibiotic regimen, in line with National Institute for Health and Care Excellence (NICE) guidelines 7.…”

Section: Introductionmentioning

confidence: 99%

“… 5 The programme was safe, resulted in significant reduction in bed occupancy and up to $A12 000 lower healthcare costs per patient. 6 The CCLG guidance was based on this programme, but used an oral antibiotic regimen, in line with National Institute for Health and Care Excellence (NICE) guidelines. 7 This approach is also supported by the evidence that the majority of clinically significant positive blood cultures in this population are identified within 24 hours of the sample being taken.…”

Section: Introductionmentioning

confidence: 99%

Can I go home now? The safety and efficacy of a new UK paediatric febrile neutropenia protocol for risk-stratified early discharge on oral antibiotics

et al. 2022

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ObjectiveTo evaluate a new protocol of risk stratification and early discharge for children with febrile neutropenia (FN).DesignProspective service evaluation from 17 April 2020 to 16 April 2021.Setting13 specialist centres in the UK.Patients405 children presenting with FN.InterventionAll children received intravenous antibiotics at presentation. Risk stratification was determined using the Australian-UK-Swiss (AUS) rule and eligibility for homecare assessed using criteria including disease, chemotherapy, presenting features and social factors. Those eligible for homecare could be discharged on oral antibiotics after a period of observation proportional to their risk group.Main outcome measuresMedian duration of admission and of intravenous antibiotics, and percentage of patients with positive blood cultures, significant infection, readmission within 7 days of initial presentation, intensive care unit (ICU) admission, death from infection and death from other causes.Results13 centres contributed 729 initial presentations of 405 patients. AUS rule scores were positively correlated with positive blood cultures, significant infection, ICU admission and death. 20% of children were eligible for homecare with oral antibiotics, of which 55% were low risk (AUS 0–1). 46% low-risk homecare eligible patients were discharged by 24 hours vs 2% homecare ineligible. Homecare readmission rates were 14% overall and 16% for low-risk cases (similar to a meta-analysis of previous studies). No child eligible for homecare was admitted to ICU or died.ConclusionsUse of the AUS rule and homecare criteria allow for safe early outpatient management of children with FN.

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Cost‐effectiveness of home‐based care of febrile neutropenia in children with cancer

Cited by 11 publications

References 33 publications

Non‐neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation

Non‐neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation

Density of antibiotic use and infectious complications in pediatric allogeneic hematopoietic cell transplantation

Can I go home now? The safety and efficacy of a new UK paediatric febrile neutropenia protocol for risk-stratified early discharge on oral antibiotics

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