Update to Guideline for Management of Fever and Neutropenia in Children With Cancer and HSCT Recipients

An update to the 2012 International Pediatric Fever and Neutropenia Guideline Panel recommendations for management of fever and neutropenia in children with cancer and hematopoietic stem cell transplantation (HSCT) recipients was reported by Lehrnbecher et al in the Journal of Clinical Oncology. New and modified recommendations are presented here. All other recommendations remained the same.

Initial Management

A3. Consider obtaining peripheral blood cultures concurrent with central venous catheter cultures (weak recommendation, moderate-quality evidence). [Change: Quality of evidence increased to moderate from low.]

A6a. In high-risk fever and neutropenia: Use monotherapy with an antipseudomonal beta-lactam, a fourth-generation cephalosporin, or a carbapenem as empiric therapy in pediatric high-risk fever and neutropenia (strong recommendation, high-quality evidence). [Change: Fourth-generation cephalosporin was added.]

Empiric Antifungal Therapy

C1. Patients at high risk of invasive fungal disease are those with acute myeloid leukemia, high-risk acute lymphoblastic leukemia, or relapsed acute leukemia as well as children undergoing allogeneic HSCT. Children with prolonged neutropenia and children receiving high-dose corticosteroids are also at high risk of invasive fungal disease. All others should be categorized as at low risk of invasive fungal disease (strong recommendation, low-quality evidence). [Change: Risk factors were refined. Quality of evidence decreased to low from moderate.]

C2a. Consider not using serum galactomannan (weak recommendation, moderate-quality evidence). [Change: Previously it had been a weak recommendation for galactomannan for surveillance and during fever and neutropenia. Now it is a weak recommendation against galactomannan and restricted recommendation to prolonged fever and neutropenia.]

C2c. Do not use fungal polymerase chain reaction testing in blood (strong recommendation, moderate quality evidence). [New recommendation]

C3a. Perform computed tomography (CT) of the lungs (strong recommendation, low-quality evidence). [Change: Quality of evidence decreased to low from moderate.]

C3b. Consider imaging of the abdomen in patients without localizing signs or symptoms (weak recommendation, low-quality evidence). [New recommendation]

C3c. Consider not routinely performing CT of the sinuses in patients without localizing signs or symptoms (weak recommendation, low-quality evidence). [Change: Previously it had been a weak recommendation for CT sinuses. Now it is a weak recommendation against CT sinuses.]

C5. In patients at low risk of invasive fungal disease with prolonged (≥ 96 hours) fever and neutropenia, consider withholding empiric antifungal therapy (weak recommendation, low-quality evidence). [Change: Previously it had been a weak recommendation for empiric therapy for patients at low risk of invasive fungal disease. Now it is a weak recommendation against empiric therapy for patients at low risk of invasive fungal disease.]

The authors concluded: “Changes to the updated fever and neutropenia [clinical practice guideline] recommendations will likely influence the care of pediatric patients with cancer and those undergoing [HSCT]. Future work should focus on closing research gaps and on identifying ways to facilitate implementation and adaptation.”

The study was supported by grants from the Canadian Institutes of Health Research and Garron Comprehensive Cancer Centre.

Lillian Sung, MD, PhD, of The Hospital for Sick Children, Toronto, is the corresponding author of the Journal of Clinical Oncology article.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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