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General guidelines for risk stratification in children with fever and chemotherapy-induced neutropenia

General guidelines for risk stratification in children with fever and chemotherapy-induced neutropenia
High-risk for severe infection or complications (1 or more)
ANC <500 cells/microL* anticipated to last for >7 days
Evidence of hepatic insufficiency (aminotransferase levels >5 times normal values)
Evidence of kidney function impairment (creatinine clearance <30 mL/min)
Comorbid medical problems including, but not limited to:
  • Hemodynamic instability
  • Oral or GI mucositis that interferes with swallowing or causes diarrhea
  • GI symptoms, including abdominal pain, nausea, vomiting, or diarrhea
  • New-onset neurologic or mental status changes
  • Signs of intravascular catheter infection, particularly catheter tunnel infection (eg, erythema, swelling and/or tenderness at the insertion site, rigors or chills associated with catheter flushing)
  • New pulmonary infiltrate or hypoxemia or underlying chronic lung disease
  • New findings or symptoms associated with localized infection
Acute lymphoblastic leukemia in infant <12 months of age
Acute myeloid leukemia
Within 30 days of hematopoietic cell transplant
Low-risk for severe infection or complications (all)
ANC <500 cells/microL expected to resolve within 7 days (ie, neutrophil count increasing)
Stable and adequate hepatic function
Stable and adequate kidney function
No active comorbidities (as listed above)
This table is intended for use in conjunction with UpToDate content on fever and chemotherapy-induced neutropenia in children. Children are assigned a risk stratum at the onset of their episode. Children initially categorized as low risk can move into the high-risk category after initial presentation if they develop a high-risk feature.

ANC: absolute neutrophil count; GI: gastrointestinal.

* The ANC threshold for high-risk defined herein differs from that in the 2010 Infectious Diseases Society of America guidelines (≤100 cells/microL anticipated to last >7 days[1]).

¶ Some centers extend this period to within 100 days of hematopoietic cell transplant.
References:
  1. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:e56.
  2. Hakim H, Flynn PM, Srivastava DK, et al. Risk prediction in pediatric cancer patients with fever and neutropenia. Pediatr Infect Dis J 2010; 29:53.
  3. Lehrnbecher T, Robinson P, Fisher B, et al. Guideline for the management of fever and neutropenia in children with cancer and hematopoietic stem-cell transplantation recipients: 2017 update. J Clin Oncol 2017; 35:2082.
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