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Risk Prediction in Pediatric Cancer Patients With Fever and Neutropenia

Hakim, Hana MD*; Flynn, Patricia M. MD*†‡; Srivastava, Deo Kumar PhD§; Knapp, Katherine M. MD*†; Li, Chenghong PhD§; Okuma, James MS§; Gaur, Aditya H. MD*

The Pediatric Infectious Disease Journal: January 2010 - Volume 29 - Issue 1 - p 53-59
doi: 10.1097/INF.0b013e3181c3f6f0
Original Studies

Background: To identify predictors for 2 risk measures—“proven invasive bacterial infection or culture-negative sepsis (IBD)” and “clinical complications (CC)”—in pediatric cancer patients with fever and neutropenia (FN).

Methods: Records of 390 patients with FN hospitalized over 2 years were reviewed. For the 332 who met inclusion criteria, one FN episode was randomly selected. Independent predictors at presentation were analyzed using multiple regression models. Optimal cut-off risk prediction scores were determined. These models were validated by bootstrap analysis.

Results: Patients' median age was 6.0 years; 66% had an underlying diagnosis of leukemia. Independent predictors of IBD (n = 56) were absolute neutrophil count <100, temperature at presentation ≥39.0°C, “sick” clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <24 reliably identified patients at low risk for IBD. Independent predictors of CC (n = 47) were relapse of malignancy, non-white race, “sick” clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <19 predicted patients at low risk for CC. Of those misclassified as low risk, 11 of 12 with IBD and 3 of 9 with CC had the outcome within 24 hours of presentation. Of the remaining patients classified as low-risk for IBD and CC, 99.5% and 97.1%, respectively, remained outcome-free after 24 hours of observation.

Conclusions: This study identifies predictors of infection/complications in pediatric patients with FN, establishes clinical cut-off scores and highlights the importance of the initial clinical impression and 24 hours of observation. These prediction models warrant prospective validation.


From the *Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN; Departments of †Pediatrics and ‡Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN; and §Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN.

Accepted for publication October 1, 2009.

Supported by a National Institutes of Health grant (CA21765) and the American Lebanese Syrian Associated Charities (ALSAC).

Presented as a poster at the 45th Annual Meeting of Infectious Diseases Society of America (IDSA), San Diego, CA, October 2007. Another part was presented as a poster at the 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC)/45th Annual Infectious Diseases Society of America (IDSA) Meeting, Washington, DC, October 2008.

The authors report no conflicts of interest.

Address for correspondence: Hana Hakim, MD, Department of Infectious Diseases, Mail Stop 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678. E-mail:

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© 2010 Lippincott Williams & Wilkins, Inc.