Haeusler Gabrielle M, Slavin Monica A, Bryant Penelope A, Babl Franz E, Mechinaud Francoise, Thursky Karin A
Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.
NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.
J Paediatr Child Health. 2018 Jul;54(7):761-769. doi: 10.1111/jpc.13899. Epub 2018 Apr 14.
Variation in the management of fever and neutropenia (FN) in children is well described. The aim of this study was to explore the current management of FN across Australia and New Zealand and highlight areas for improvement.
A practice survey was administered to paediatric health-care providers via four clinical and research networks. Using three clinical case vignettes, we explored risk stratification, empiric antibiotics, initial investigations, intravenous-oral switch, ambulatory management and antibiotic duration in children with cancer and FN.
A response was received from 104 participants from 16 different hospitals. FN guideline compliance was rated as moderate or poor by 24% of respondents, and seven different fever definitions were described. There was little variation in the selected empiric monotherapy and dual-therapy regimens, and almost all respondents recommended first-dose antibiotics within 1 h. However, 27 different empiric antibiotic combinations were selected for beta-lactam allergy. An incorrect risk status was assigned to the low-risk case by 27% of respondents and to the high-risk case by 41%. Compared to current practice, significantly more respondents would manage the low-risk case in the ambulatory setting provided adequate resources were in place (43 vs. 85%, P < 0.0001). There was variation in the use of empiric glycopeptides as well as use of aminoglycosides beyond 48 h.
Although the antibiotics selected for empiric management of FN are appropriate and consistent, variation and inaccuracies exist in risk stratification, the selection of monotherapy over dual therapy, empiric antibiotics chosen for beta-lactam allergy, use of glycopeptides and duration of aminoglycosides.
儿童发热伴中性粒细胞减少症（FN）的管理差异已有充分描述。本研究旨在探讨澳大利亚和新西兰目前对FN的管理情况，并突出需要改进的方面。
通过四个临床和研究网络向儿科医疗服务提供者进行了一项实践调查。我们使用三个临床病例 vignettes，探讨了癌症合并FN患儿的风险分层、经验性抗生素使用、初始检查、静脉-口服转换、门诊管理和抗生素使用时长。
收到了来自16家不同医院的104名参与者的回复。24%的受访者将FN指南依从性评为中等或较差，并且描述了七种不同的发热定义。所选的经验性单药治疗和联合治疗方案差异不大，几乎所有受访者都建议在1小时内给予首剂抗生素。然而，针对β-内酰胺过敏选择了27种不同的经验性抗生素组合。27%的受访者将低风险病例的风险状态判定错误，41%的受访者将高风险病例的风险状态判定错误。与当前实践相比，如果有足够的资源，显著更多的受访者会在门诊环境中管理低风险病例（43%对85%，P<0.0001）。经验性糖肽类药物的使用以及48小时后氨基糖苷类药物的使用存在差异。
尽管为FN经验性管理选择的抗生素是合适且一致的，但在风险分层、单药治疗与联合治疗的选择、针对β-内酰胺过敏选择的经验性抗生素、糖肽类药物的使用以及氨基糖苷类药物的使用时长方面存在差异和不准确之处。
