Rationalizing the approach to children with fever in neutropenia

Fever in neutropenia is the most frequent potentially life-threatening complication of chemotherapy in children and adolescents with cancer. This review summarizes recent studies that refine our knowledge of how to manage pediatric fever in neutropenia, and their implications for clinical practice and research.

Many studies have focused on improving risk stratification based on clinical and laboratory characteristics, and on stepping-down treatment in low-risk episodes. New diagnostic strategies are in their infancy, including use of polymerase chain reaction (PCR) methods and cross-sectional imaging. Increasing use of systematic review and meta-analysis has helped to consolidate research and to reduce or identify uncertainties in many areas.

Our understanding of the cause of fever in neutropenia has been improved by PCR-based diagnostics, but the clinical implications remain unclear. Many risk-prediction models have been developed, but none is useful for clinical practice as yet. First-day outpatient management, with oral or intravenous antibiotics, is now known to be efficacious and cost-effective for pediatric low-risk fever in neutropenia. Before implementing this regimen as new standard of care, its safety should be assessed. Internationally supported evidence-based guidelines for pediatric fever in neutropenia are being developed. They have the potential to rationalize everyday practice, and stimulate further research.