Colorado University. US: A University of Colorado Cancer Center study published in the journal Pediatric Blood & Cancer
shows that pediatric cancer patients who receive antibiotics within 60
minutes of reporting fever and showing neutropenia (low neutrophil
count), go on to have decreased intensive care needs and lower mortality
compared with patients who receive antibiotics outside the 60-minute
window.
“We’re talking about kids who have gone home after chemotherapy and
then a parent calls the hospital reporting a fever. The question is can
we get the patient back to the hospital, then get a white cell count,
and get antibiotics on board when needed all within an hour of their
arrival? It’s a huge challenge. This study shows that it’s important we
make it happen: there’s less intensive care and fewer fatalities for
kids who get antibiotics sooner,” says Joanne Hilden, MD, investigator
at the CU Cancer Center, director of clinical services for pediatric
oncology at Children’s Hospital Colorado, and the paper’s senior author.
Specifically, the paper shows in a sample of 220 children that
mortality was 3.9 percent for patients who received antibiotics outside
60 minutes and only 0.7 percent for those who received antibiotics
within the hour.
The study took place within efforts of Children’s Hospital Colorado
to improve time-to-delivery of antibiotics in cases of fever and low
white blood cell count in pediatric cancer patients, which at study
outset required an average 150 minutes. The paper describes procedural
changes including prescribing antibiotics upon a pediatric cancer
patient’s arrival to the hospital, holding that order, then allowing the
delivery of antibiotics to start immediately after learning the results
of neutrophil count testing (eliminating the need to find a prescriber
once the white blood cell count was known).
Another intervention describes speeding the time needed to determine
the neutrophil count. Traditionally, determining neutropenia requires a
full white blood cell count followed by “differential” (counting the
percent neutrophils) by a human technician. But human verification
reverses the preliminary, machine results in less than 0.5 percent of
cases. Analysis showed that the benefit of speed outweighed the risk of
administering unneeded antibiotics in these very few cases. Depending on
preliminary rather than technician-verified results of white cell
counts reduced the time of testing from 45 minutes to twenty.
“Another thing we show is that just increasing the awareness of how
important it is to get antibiotics on board quickly in these cases
speeds delivery,” Hilden says.
Taken together, along with changes to clinic flow procedures that
included notifying the full care team as soon as the family is advised
to come into the hospital and a STAT intake, Children’s Hospital
Colorado was able to reduce its time to delivery of antibiotics to a
median 46 minutes, with nearly 100 percent of pediatric patients with
fever and neutropenia receiving antibiotics within 60 minutes.
“We’re a top children’s cancer institution where we deliver medicines
based on the latest molecular genetics. And even if you get all that
stuff right, you still have to take care of the patient’s body during
treatment. Nothing makes you madder than losing to infection,” Hilden
says. “Only eleven percent of pediatric cancer patients with fever and
neutropenia have serious complications. That’s low. But we can make it
zero, and this study shows that getting antibiotics onboard quickly goes
a long way toward that goal.”