Lucas K G, Brown A E, Armstrong D, Chapman D, Heller G
Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, 10021, USA.
Cancer. 1996 Feb 15;77(4):791-8.
The management of pediatric oncology patients with fever and neutropenia assumes that all patients are at risk for bacteremia, and therefore generally involves hospitalization and broad-spectrum parenteral antibiotics for all patients. The determination of which patients are at low risk for having positive blood cultures and for developing complications related to bacteremia is of potential benefit.
The records of 161 pediatric patients with neoplastic disease hospitalized for 509 episodes of fever and neutropenia between January 1990 and June 1992 were retrospectively reviewed. Clinical features at initial presentation, clinical and microbiologic documentation of infection, and outcome were analyzed.
The only presenting clinical features that correlated with an increased likelihood of having positive blood cultures were chills, hypotension, the requirement for fluid resuscitation (P < 0.001), or a diagnosis of leukemia or lymphoma (P < 0.041). Leukemia patients with relapse admitted for fever and neutropenia were no more likely to have positive blood cultures than those patients in remission. There were ten episodes of fever and neutropenia in which patients were transferred to the intensive care unit (ICU), and two sepsis related deaths. Nine episodes involving ICU management and both deaths were in patients who had persistent fever and an absolute neutrophil count (ANC) of less than 100 after 48 hours of hospitalization (n = 177). Patients with an ANC of less than 100 after 48 hours were twice as likely to have antibiotic changes, 15 times more likely to receive amphotericin B, and were hospitalized twice as long as patients with an ANC of 100 or higher after 48 hours.
Children hospitalized for fever and neutropenia who have persistent fever and an ANC of less than 100 after 48 hours are at high risk for morbidity and are more likely to require antibiotic changes and antifungal therapy. Children who initially lack signs of sepsis, are afebrile, and have an ANC of 100 or higher after 48 hours are at low risk for complications and could be selectively discharged on antimicrobials after a 48-hour period of inpatient hospitalization.
小儿肿瘤患者出现发热伴中性粒细胞减少时，通常假定所有患者都有菌血症风险，因此一般所有患者都需住院并接受广谱肠外抗生素治疗。确定哪些患者血培养阳性及发生菌血症相关并发症的风险较低可能有益。
回顾性分析1990年1月至1992年6月期间因发热伴中性粒细胞减少住院509次的161例小儿肿瘤患者的病历。分析初始表现的临床特征、感染的临床及微生物学记录以及结局。
与血培养阳性可能性增加相关的唯一初始临床特征是寒战、低血压、需要液体复苏（P<0.001）或白血病或淋巴瘤诊断（P<0.041）。因发热伴中性粒细胞减少入院的复发白血病患者血培养阳性的可能性并不高于缓解期患者。有10次发热伴中性粒细胞减少发作时患者被转入重症监护病房（ICU），2例死于脓毒症。涉及ICU管理的9次发作及2例死亡均发生在住院48小时后仍持续发热且绝对中性粒细胞计数（ANC）低于100的患者中（n = 177）。住院48小时后ANC低于100的患者更换抗生素的可能性是ANC为100或更高患者的两倍，接受两性霉素B治疗的可能性高15倍，住院时间是后者的两倍。
因发热伴中性粒细胞减少住院的儿童，若住院48小时后仍持续发热且ANC低于100，则发病风险高，更可能需要更换抗生素及抗真菌治疗。最初无脓毒症体征、不发热且住院48小时后ANC为100或更高的儿童并发症风险低，住院48小时后可选择性出院并接受抗菌药物治疗。
