Granulocyte transfusion improves survival and clinical recovery in pediatric febrile neutropenia: A 15-year real-world cohort study from Thailand

Abstract Background: Febrile neutropenia (FN) remains a leading cause of morbidity and mortality in pediatric patients with high-risk hematologic disorders, particularly in low- and middle- income countries (LMICs), where antimicrobial resistance limits treatment options. Granulocyte transfusion (GT) is considered adjunctive therapy, but pediatric data from LMICs are limited. Methods: This 15-year retrospective cohort study included pediatric patients (<18 years) with severe neutropenic infections treated at a national tertiary referral center in Thailand (2009-2023). Patients received GT plus antimicrobial therapy or antimicrobial therapy alone. The primary outcome was 30-day survival. The analyzes included multivariable logistic regression, Cox regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Results: Among 54 patients (26 GT, 28 control), GT was associated with an improvement in 30-day survival in the full cohort (OR 0.105, 95% CI: 0.016 0.700; p = 0.020). IPTW confirmed this association (OR 0.099; p = 0.001), with consistent results in the PM analysis (OR 0.157; p = 0.028). In the high-risk hematologic subgroup (n = 48), GT was associated with increased survival (95.2% vs 61.9%; HR 0.105; p = 0.034). GT also accelerated the resolution of fever (HR 2.24; p = 0.028), febrile neutropenia recovery (HR 2.35; p = 0.017), and absolute neutrophil count (ANC) recovery (HR 2.10; p = 0.047). No serious transfusion- related adverse events were observed. Conclusions: GT was associated with improved survival and faster clinical recovery in pediatric FN. These real-world LMIC data support GT as a feasible adjunctive therapy and warrant prospective validation. Keywords: granulocyte transfusion, febrile neutropenia, pediatric hematology, LMIC, survival, infection Key Message Granulocyte transfusion significantly improved 30-day survival in pediatric febrile neutropenia, with GT recipients achieving 92.3% versus 65.4% survival at 30 days (adjusted OR 0.105; p = 0.020). Secondary outcomes showed a trend toward better 90-day survival (p = 0.071), faster fever resolution (HR 2.24; p = 0.028), accelerated FN recovery (HR 2.35; p = 0.017), and quicker ANC recovery (HR 2.10; p = 0.047), with no serious adverse events observed.