Low Socioeconomic Status Is Associated with Prolonged Times to Assessment and Treatment, Sepsis and Infectious Death in Pediatric Fever in El Salvador

Abstract

BackgroundInfection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.MethodThis prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.FindingsOf 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62–119.10; P = 0.016).InterpretationIlliteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.

Optimizing outcomes for children with non‐Hodgkin lymphoma in low‐ and middle‐income countries by early correct diagnosis, reducing toxic death and preventing abandonment

“…This is not surprising considering how rapidly Burkitt lymphoma can grow, such that any treatment gaps provide an opening for disease to progress (Patte et al , ). The intense block regimens in HIC include high‐dose methotrexate, alkylating agents, anthracyclines, vincristine, glucocorticoids and intrathecal methotrexate in doses that induce severe neutropenia, lymphopenia, thrombocytopenia and mucositis, requiring intense supportive care including management of infection, haemorrhage, drug‐specific toxicities and nutrition (Patte et al , ; Howard et al , , ; Gavidia et al , ; Israels et al , ; Bhojwani et al , ; Gupta et al , ; Ladas et al , ). Patients usually develop profound aplasia and opportunistic infections, which necessitate rapid access to intensive life‐support.…”

Barriers to Cure for Children with Cancer in India and Strategies to Improve Outcomes: A Report by the Indian Pediatric Hematology Oncology Group

“…A high incidence of sepsis has been demonstrated in pediatric patients receiving chemotherapy, approximately 12.8% in children aged 1-9 years and 17.4% in children aged 10 Barriers to Cure of Childhood Cancer  neutropenia a serious and worrying complication in pediatric cancer treatment [17]. Studies on febrile neutropenia from PODC are few [18], but febrile neutropenia remains a major cause of hospitalization apart from admissions for chemotherapy administration. A study from India on patterns of mortality in children with ALL identified sepsis (53.3%) and bleeding (15.7%) as the most common causes of mortality [19].…”

A Cross-sectional Study of Undiagnosed Fever in a Rural Population at a Tertiary Care Hospital of West Bengal

“…This results in longer hospital stay and increased cost of treatment. [6] The etiological pattern in both Indian and Western studies over the years are more or less similar showing infections as the most common cause. TB was found to be the most common infection causing FUO not only in India but also in studies done in Turkey and Taiwan.…”