Febrile Neutropenia (FN) episodes in pediatric oncologic patients admitted in an Oncologic Pediatric Intensive Care (PICU)

Background

FN is a frequent complication of chemotherapy treatment in children with oncological diseases. It can cause serious complications due to infections, such as sepsis and septic shock. A target approach involves identifying microorganisms, understanding both documented and undocumented infections, and acting in a targeted manner.

Methods

Retrospective, descriptive and analytical study conducted through a review of medical records of cancer patients from 0 to 18 years old with FN episodes admitted to the PICU in Barretos Cancer Children’s Hospital, from June/2013 to January/2018, some patients had more than one episode. Epidemiological, clinical and types of infection were analyzed for survival outcome. The rates of severe sepsis, septic shock, and mortality were investigated.

Results

Data from 140 FN episodes were analyzed, in 120 patients. Most of the children had hematological diseases (80.8%), which were mainly Acute Lymphocytic Leukemia (ALL), and Acute Myeloid Leukemia (AML). The average age was 8.5 years old, and the main microorganisms identified in cultures were Gram negative bacteria. In the first FN episodes the most frequent bacterial microorganisms identified were Escherichia coli (14.51%), Klebsiella pneumoniae (14.51%), Staphilococcus epidermidis (6.45%), Streptococcus viridans (6.45%), and Clostridioides difficile (3.22%). The most frequent fungus were Candida tropicalis (4.83%), Candida albicans (3.22%), and Candida krusei (3.22%). In the second FN episodes the most frequent microorganisms identified were Klebsiella pneumoniae (22.25%), Acnitetobacter sp (22.25%), Streptococcus viridans (11.10), and Murcor sp (11.10%). The most frequent antimicrobial used in the first episodes were Vancomycin (77.5%), Cefepime (73.30%), Metronidazole (41.7%), Amikacin (32.5%) and Meropenem (24.2%), and the most frequent antimicrobial used in the second episodes were Vancomycin (95%), Cefepime (70%), Meropenem (30%), Metronidazole (25%), and Amikacyn (15%). The documented microorganisms and clinical infections were more frequent than foci of undetermined origin, as shown in figures number 1 and 2.

In multivariate analysis variables included all other oncological diseases (Hodgkin's lymphoma, Juvenile Myelomonocytic Leukemia and solid tumors) versus hematological tumors in relapse (ALL in relapse, AML in relapse and Non-Hodgkin Lymphoma (NHL), in relapse), p=0.007, showing a 3.10 times higher risk of death for the second group.

Conclusions

The rate of severe sepsis was 38.57%, the rate of septic shock was 37.85%, and the rate of mortality was 25.71%, a total of 36 patients died and 84 patients were discharged. The most severe infections were in hematological malignant patients, principally in relapse.

It is important an early detection of sepsis and septic shock in FN episodes as well as a prompt detection of types of infection and microorganisms to reach best outcomes and to decrease the mortality rate.