title: Management of fever and neutropenia in children with cancer.
abstract: OBJECTIVE
  Febrile neutropenia remains a common, life-threatening complication of chemotherapy in paediatric oncology. Delays in institution of empiric antibiotics have been identified at tertiary and regional centres caring for these patients and associated with decreased survival. Our objective was to reduce the time to administration of empiric antibiotics to less than 60 min from the time of presentation to hospital.
  
  
  METHODS
  A retrospective study of the records of oncology patients presenting to the emergency department of a tertiary hospital over a 3-month period was performed and time to first antibiotic administration recorded. Potential causes of delay in commencement of antibiotics were identified and an algorithm-based approach to the management of fever in immunocompromised children developed and implemented. Follow-up evaluation data were collected at 12 and 60 months post-intervention. Causes of delay in commencement of antibiotics at regional hospitals that share care with the tertiary hospital were identified through questionnaires, interviews and focus groups, involving patients and medical and nursing staff. The impact of the introduction of the algorithm at one peripheral hospital was evaluated.
  
  
  RESULTS
  The mean time to empiric antibiotics was reduced from 148 min (95% confidence interval (CI) 81-216) at baseline to 76 min (95% CI 50-101) at 12 months post-intervention and sustained at 65 min (95% CI 52-77) 5 years after the intervention. At the peripheral hospital, mean time to antibiotic delivery was reduced from 221 min (95% CI 114-328) to 65 min (95% CI 42-87) at 12 months after the intervention.
  
  
  CONCLUSIONS
  The introduction of the guideline, with teaching and support for staff and parents, resulted in an improvement in practice, meeting international guidelines and achieving sustained results at 5 years after introduction at a tertiary hospital. The guideline has been shown to be feasible and effective at a regional hospital.
authors.affiliation: Kids Cancer Centre, Sydney Children's Hospital, High Street, Randwick, NSW, 2031, Australia, a.vedi@unsw.edu.au.
authors.forename: A
authors.initials: A
authors.lastname: Vedi
authors.forename: V
authors.initials: V
authors.lastname: Pennington
authors.forename: M
authors.initials: M
authors.lastname: O'Meara
authors.forename: K
authors.initials: K
authors.lastname: Stark
authors.forename: A
authors.initials: A
authors.lastname: Senner
authors.forename: P
authors.initials: P
authors.lastname: Hunstead
authors.forename: K
authors.initials: K
authors.lastname: Adnum
authors.forename: W
authors.initials: W
authors.lastname: Londall
authors.forename: L
authors.initials: L
authors.lastname: Maurice
authors.forename: Claire
authors.initials: C
authors.lastname: Wakefield
authors.forename: R J
authors.initials: RJ
authors.lastname: Cohn
mesh_terms: D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D064146:Chemotherapy-Induced Febrile Neutropenia / Q000175:diagnosis* / Q000188:drug therapy*; D002648:Child; D054869:Clinical Audit; D003657:Decision Making; D004334:Drug Administration Schedule; D006801:Humans; D009369:Neoplasms / Q000097:blood / Q000188:drug therapy; D012189:Retrospective Studies; D011795:Surveys and Questionnaires
chemical_list: D000900:Anti-Bacterial Agents