Febrile Neutropenia in Pediatric Cancer Patients: Etiology, Complications, and Outcomes in a Low-Resource Setting

Background

Febrile neutropenia (FN) presents a significant, life-threatening risk for pediatric cancer patients undergoing chemotherapy. Epidemiological studies in this population reveal sepsis rates of approximately 12.8% in children aged 1 to 9 years and 17.4% in those aged 10 to 19 years. This study examines the characteristics, etiology, and outcomes of FN in pediatric patients at our institution.

Methods

We conducted a descriptive study involving pediatric patients diagnosed with FN at a tertiary hospital in the Philippines from January 1, 2021, to December 31, 2023. Inclusion criteria encompassed patients who presented with FN and were managed according to institutional guidelines, including appropriate blood cultures and available information on clinical outcomes. Patients were categorized into high-risk (leukemia, lymphoma, JMML, or MDS) and low-risk (solid tumors) groups.

Results

A total of 124 FN episodes were included after excluding non-chemotherapy-related cases and those occurring during hospitalization. The median age of patients was 6 years (range: 10 months to 19 years), with 74.5% being male. Primary diagnoses included leukemia and lymphoma (53.2%), solid tumors (34.6%), and relapsed malignancies (11.2%). Antibacterial prophylaxis was administered to 53.2% of patients, whereas antifungal prophylaxis was administered minimally (4.1%). The median time since the last chemotherapy was 8 days.

In the high-risk group (n=93), fever of unknown origin accounted for 23.4% of cases, with proven infections (bacteremia and pneumonia) at 12.9%. In the low-risk group (n=31), 25% also presented with fever of unknown origin. Complications in high-risk patients included bleeding requiring transfusion (24%), altered sensorium (12%), and ICU admissions (16%).

Outcomes demonstrated a mortality rate of 10% in high-risk and 6.5% in low-risk patients within two weeks of FN diagnosis. High-risk patients had longer hospitalizations (median: 10.5 days) compared to low-risk patients (median: 4.5 days), with ICU stays averaging 5.5 days for high-risk and 4.5 for low-risk patients.

Pathogen isolation showed a predominance of Klebsiella pneumoniae and Escherichia coli in blood cultures. Urine cultures revealed a high frequency of ESBL-producing organisms, and respiratory pathogens included SARS-CoV2, underscoring the importance of monitoring viral infections.

Conclusion

High-risk patients face unique challenges, demonstrated by greater mortality, longer hospital stays, and increased complications. Understanding infection spectra and pathogen profiles is essential for enhancing therapeutic approaches and outcomes in this vulnerable population. Continuous efforts to refine management protocols and improve supportive care are crucial for mitigating the risks associated with FN in pediatric oncology.