Defining Low Risk and High Risk Categories
Low risk assessment usually incorporates several criteria which are based on history, physical examination and laboratory values. Criteria for low risk includes (list non exhaustive and varies by centre):
- age (>1years)
- malignancy in remission
- Relapse protocol
- Sepsis in the past 4 weeks
- Severe mucositis
- No clinical signs of sepsis or focal signs of infection
- Clinically well with viral symptoms/Presence of symptoms of URTI
- ANC >0.3x109/L
- CRP <10 mg/L
- Reliable parents and easy access to hospital
Many patients are “high risk” for the development of sepsis and invasive bacterial disease. These patients are not eligible for outpatient therapy:
- Patients undergoing intense chemotherapy such as with AML, on relapse protocols or post-HSCT.
- A recent episode of proven bacterial sepsis.
- Expected neutropenia for more than 1 week.
- Severe mucositis.
- Clinical suspicion of typhlitis.
order to cover for the range of pathogens encountered in the setting of FN, the prompt administration of broad spectrum antibiotic therapy is essential.
The use of monotherapy vs. combination therapy with an aminoglycoside has been much debated in the literature. However multiple trials and meta-analyses in adult patients has showed no significant benefit for the combination therapy in terms of survival or treatment failure, while adverse events (i.e.: nephrotoxicity) are more common with combination treatment 9. The paediatric data is somewhat more limited, but the recent evidence seems to show similar efficacy using monotherapy vs. combination with an aminoglycoside 10-13.