1. Febrile Neutropenia Chart Review and New Guideline Stephanie Eason RN, CPHON Kids Rock Conference October 2014

2. Atlantic Canada Chart Review  APPHON reviewed charts of patients diagnosed with Febrile Neutropenia between Jan. 1, 2005 – Jan. 31, 2011  NL; NS; NB; PEI  Janeway was only hospital in NL  Multiple sites in other provinces

3. Atlantic Canada Chart Review  Indicators examined were based on APPHON guideline for treatment of F/N: 1.time blood cultures were drawn 2.time antibiotics were started

4. How much time should pass between patient presentation and when blood cultures are drawn? 1.10 minutes 2.30 minutes 3.1 hour

5. Time to Blood Cultures – Target: 30 Minutes  Atlantic Canada Department# casesmean (minutes) ER16693 OPD8486 Inpatient10371  Janeway Department# casesmean (minutes) ER3973 MDC1767 Inpatient2027

6. WHY ?  Busy  Sicker patients in ER  Child does not appear unwell  Unable to access CVAD  Waiting for orders to be written

7. How much time should lapse between patient presentation and start of antibiotics? 1.30 minutes 2.1 hour 3.2 hours

8. Time to Antibiotics – Target: 60 Minutes  Atlantic Canada Department# casesmean (minutes) ER166172 OPD84115 Inpatient103102  Janeway Department# casesmean (minutes) ER3993 MDC1786 Inpatient2062

9. Why?  Waiting on lab results (CBC)  Finding someone to access CVAD  Busy  Child does not look sick  Not familiar with guideline for treatment  Parent/patient interference

10. Conclusions  Significant time delays to drawing blood culture and to starting antibiotics across all departments and all sites.  Departments who saw more oncology patients were more likely to adhere to guideline.

11. Recommendations  More education is needed to disseminate APPHON Guideline for treatment of Febrile Neutropenia.  If CBC is not back in one hour—antibiotics need to be started. If it is later determined that the patient is not neutropenic, antibiotics can be discontinued. (increased rate of complications when abx delayed beyond 1 hour. Pediatric Blood and Cancer 60:1299, 2013)

13. Definition of Fever*  Single elevation ≥38.3 O C orally (37.8 O C axillary)  Two elevations ≥38 O C orally (37.5 O C axillary) taken at least 1 hour apart  Temperature taken by parents at home MUST be counted. * only for pediatric oncology patients

14. Definition: Neutropenia ANC less than 0.5 x 10 9 /L OR 1 x 10 9 /L and expected to fall ANC = (%segs + %bands) x total WBC count ------------------------------------100 Mature neutrophils can be called neutrophils or segs. Immature neutrophils can be called stabs or bands.

15. Average Risk No high risk factors High Risk Any one of high risk factors Piperacillin/tazobactam 240 mg/kg/day (of piperacillin component) IV q8h Start antibiotics within 1 hour of discovering fever. Piperacillin/tazobactam 240 mg/kg/day (of piperacillin component) IV q8h AND Vancomycin 50 mg/kg/day IV q6h Start antibiotics within 1 hour of discovering fever. Blood Culture result NegativePositive Continue IV antibiotics until advised by oncologist Febrile Neutropenia Single temperature greater than or equal to 38.3 o C orally OR two temperatures greater than or equal to 38 o C orally at least 1 hour apart ANC less than 0.5 x 10 9 /L OR 1 x 10 9 /L and expected to fall Reassess Discontinue antibiotics when all criteria has been met: negative blood culture at 48 hours, afebrile for at least 24 hours, clinically stable, ANC rising on at least 2 consecutive days. High Risk Factors: History of sepsis in last 6 months HSCT within 6 months &/or receiving immunosuppressant AML Down Syndrome Advanced stage Burkitt Lymphoma Relapsed Leukemia Clinically unstable (see signs & symptoms below) Signs & symptoms of clinical instability: Sepsis syndrome Hypotension Tachypnea Hypoxia (o 2 sats<94% in room air) New infiltrates on CXR Altered mental status Severe mucositis Vomiting Abdominal pain Evidence of local infection Penicillin allergy: (average & high risk) Ceftazidime 150 mg/kg/day IV q8h AND Vancomycin 50 mg/kg/day IV q6h Please contact Pediatric Hematologist/Oncologist on-call at 709-777-6300 to discuss all patients.

16. QUESTIONS ?