Karen Selwood

Variation in policies for the management of febrile neutropenia in United Kingdom Children’s Cancer Study Group centres

Objective: To assess the variation in the current UK management strategies for the treatment of febrile neutropenia in childhood. Design and setting: A postal survey of all 21 United Kingdom Children’s Cancer Study Group (UKCCSG) centres assessing and collating local policies, protocols or guidelines relating to the management of febrile neutropenia. Further direct contact was undertaken to clarify any uncertainties. Results: All 21 centres provided information. The policies used to manage febrile neutropenia in the centres around the UK vary in almost every aspect of management. Definitions of fever ranged from a persistent temperature of >37.5°C to a single reading of >39°C. Neutropenia was inconsistently defined as an absolute neutrophil count of <1×109, <0.75×109 or <0.5×109. Choices of antibiotic approaches, empirical modifications and antistaphylococcal treatment were different in each protocol. The use of risk stratification was undertaken in 11 centres, with six using a policy of reduced intensity therapy in low risk cases. Empirical antifungal treatment was very poorly described and varied even more widely. Conclusions: There was a great deal of variation in definitions and treatment of febrile neutropenia in the UKCCSG children’s cancer treatment centres. A degree of variation as a result of local microbiological differences is to be expected, but beyond this we should seek to standardise the core of our approach to defining fever and neutropenia, risk stratification and duration of empirical therapy in a way that maintains safety, minimises resource utilisation and maximises quality of life.

Assessment and management of nutritional challenges in children’s cancer care: A survey of current practice in the United Kingdom

BACKGROUND The maintenance of an adequate nutritional intake is vital for the child or young person undergoing treatment for cancer. Inability to maintain nutrition can lead to poor tolerance of treatment, increased risk of infectious complications and a potential poorer overall outcome. Good nutritional support is vital however there does not appear to be a national or consistent approach to either nutritional support or assessment. PURPOSE The Paediatric Oncology Nurses Forum of the Royal College of Nursing and the Paediatric Oncology Dieticians Interest Group surveyed practice in the 21 Children Cancer and Leukaemia Group Centres in the United Kingdom and Ireland with the express aim of reviewing current practice as a first stage towards developing national guidance for nutritional management. METHODS AND SAMPLE Questionnaires designed to review nutritional assessment and nutritional interventions were distributed to both a nurse and dietician in each CCLG centre. The results were analysed using descriptive statistics. RESULTS There was a 100% return rate from nurses and 66% from dieticians. The results showed an inconsistent approach in both assessment methods and approaches to nutritional intervention for this group of patients. CONCLUSION It is recognised that there is a need to adequately assess and provide appropriate nutrition for children and young people receiving cancer therapies. This survey highlights the inconsistencies in practice today as well as the need for consistent and useful guidance especially in the area of nutritional assessment and management of potential malnutrition.

Developing a national ‘low risk’ febrile neutropenia framework for use in children and young people's cancer care

PurposeA Delphi study was undertaken to develop a framework guidance that would rationalise and standardise the care of children with febrile neutropenia (FNP) across the UK.MethodsA mailed Delphi survey was undertaken with health professionals working in childrens cancer units. The survey employed two rounds of feedback on 22 practice statements drawn from a systematic review of clinical evidence. Consensus was assumed for any statement where 80+ % of respondents indicated that they “agreed” or “strongly agreed”.ResultsConsensus was reached on 21 of the 22 practice statements in round 1 that were categorised into six areas: definition of fever and neutropenia, initial management and choice of antibiotic, defining low-risk patients, strategy in low-risk patients and alternative approaches. Consensus could not be reached on whether patients needed to be afebrile to be suitable for discharge and the required length of outpatient antibiotic treatment.ConclusionsA Delphi survey allowed the successful development of a national framework for identification and management of children with FNP. The use of an existing well-functioning professional network was key in this projects success.

A reaudit of current febrile neutropenia practice in UK paediatric oncology centres prior to implementation of NICE guidance

In September 2012, the National Institute for Clinical Excellence (NICE) published ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’.1 No national guidelines for the management of neutropenic sepsis in children have been previously published. In 2008, the Childrens Cancer and Leukaemia Group produced a framework document for the treatment of febrile neutropenia (FN), based on a literature review and a Delphi survey.2 This document was designed to provide an evidence-based approach that could be used to inform local …

Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients (NICE Clinical Guideline CG151)

Information about current guideline In September 2012, the National Institute for Clinical Excellence (NICE) published a guideline entitled ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’.1 The aim of the guideline is to ‘improve outcomes by providing evidence-based recommendations on the prevention, identification and management of this life-threatening complication of cancer treatment’ for children, young people and adults. The National Collaborating Centre for Cancer was commissioned by NICE to develop the guideline and establish a Guideline Development Group, including children and young peoples cancer nurses and consultants, which reviewed the evidence and developed the recommendations. Previous guideline There are no previously published national guidelines for the management of neutropenic sepsis in children. In July 2008, the Childrens Cancer and Leukaemia Group (CCLG) produced a framework document for the treatment of febrile neutropenia, focusing on the definitions of fever and neutropenia, and on developing a practical management strategy for low-risk patients, which individual centres could incorporate into local policies. The document was produced in response to a survey suggesting wide variation in the definitions and management of febrile neutropenia, following an exhaustive literature review, small group discussion and a national Delphi consensus process.2 ,3 A recent audit of UK paediatric oncology centres revealed that current practice differs widely from recommendations contained within the CCLG framework.4 Box 2 ### Resources Controversial and key issues that the guideline addresses

Children with cancer: quality of information for returning to school.

A childrens oncology unit in the UK carried out an initial audit of the information given by healthcare professionals to children, families, teachers and educational institutions about the return to school of pupils with cancer. The findings were collated and presented to those involved. The audit has led to the provision of more consistent, continuing information to families and schools.

Once-daily netilmicin for neutropenic pyrexia in paediatric oncology

Aim: To establish the safety and efficacy of single daily intravenous netilmicin 6 mg/kg with piperacillin 100 mg/kg every 8 h for empirical, first‐line management of children with neutropenic pyrexia following cytotoxic chemotherapy. Methods: Observational study of children admitted to a regional oncology unit from October 1999–April 2002. Primary outcome measure was temperature 72 h after commencing antibiotic therapy; secondary measures were mortality, nephrotoxicity, symptomatic ototoxicity and serum netilmicin levels. Results: 280 episodes for 128 patients (median age 7.1 y) were documented, and 248 episodes were evaluated and compared with a previous cohort of 100 episodes for which the only difference was administration of netilmicin three times daily. Twenty‐seven per cent of single‐dose netilmicin episodes remained febrile at 72 h compared to 32% in the comparator group (difference – 4.7%; 95% CI: – 6.8% to 16.2%; p= 0.41). No patients died and we were unable to find evidence of nephrotoxicity or ototoxicity. Eighty‐nine per cent of “peak” serum netilmicin levels measured 30 min after infusion were 10 mg/l or greater, and 94% and 86% measured 12–16 h after the first and third dose, respectively, were 1 mg/l or less. Peak serum netilmicin level measurements and 12–16‐h measurements after the first dose were abandoned after the first 180 episodes.

Vascular access for daunorubicin during childhood acute lymphoblastic leukaemia induction treatment: a UKCCSG supportive care group and MRC childhood leukaemia working party survey.

Daunorubicin was reintroduced into induction chemotherapy in UK protocols for intermediate- and high-risk childhood acute lymphoblastic leukaemia in 1999. Concern about the risk of central venous catheter-associated venous thromboembolism led to a recommendation that induction treatment should be given by peripheral venous access wherever possible, whilst recognising anxieties concerning the risk of daunorubicin extravasation. A survey performed to determine how these conflicting concerns influenced practice in the administration of daunorubicin revealed considerable variation. The results highlight that recommendations were not being followed and that local practice and guidance were being utilised in this area of practice. However, there is a need to identify patients at higher risk of venous thromboembolism during induction treatment and better strategies to prevent this complication.

A survey of public transport use by immunocompromised children in the United Kingdom.

The advice given to immunocompromised children and their families on the use of public transport at our oncology unit has been inconsistent, with a lack of written or evidence based guidelines. We therefore carried out two surveys, one national and one local on this issue, to determine what advice is given to families. We also undertook an extensive literature search on this subject.