title: Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric fever in El Salvador.
abstract: BACKGROUND
  Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.
  
  
  METHODS
  This prospective cohort study included children aged 0-16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.
  
  
  RESULTS
  Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0-20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0-3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09-8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03-1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62-119.10; P = 0.016).
  
  
  CONCLUSIONS
  Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.
authors.affiliation: Pediatric Oncology, Benjamin Bloom National Children's Hospital, San Salvador, El Salvador.
authors.forename: Ronald
authors.initials: R
authors.lastname: Gavidia
authors.forename: Soad L
authors.initials: SL
authors.lastname: Fuentes
authors.forename: Roberto
authors.initials: R
authors.lastname: Vasquez
authors.forename: Miguel
authors.initials: M
authors.lastname: Bonilla
authors.forename: Marie-Chantal
authors.initials: MC
authors.lastname: Ethier
authors.forename: Caroline
authors.initials: C
authors.lastname: Diorio
authors.forename: Miguela
authors.initials: M
authors.lastname: Caniza
authors.forename: Scott C
authors.initials: SC
authors.lastname: Howard
authors.forename: Lillian
authors.initials: L
authors.lastname: Sung
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004544:El Salvador / Q000453:epidemiology; D005260:Female; D005334:Fever / Q000150:complications*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007938:Leukemia / Q000150:complications; D008297:Male; D018805:Sepsis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D012923:Social Class; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents