Antibiotic Escalation Within the First 72 Hours of Febrile Neutropenia: Association With Biomarkers and Clinical Outcomes

Aim: To determine the rate of antibiotic escalation within the first 72 hours of FN (Febrile neutropenia) episodes in pediatric patients and to evaluate the association of escalation with inflammatory biomarkers and clinical outcomes.Methods: We retrospectively reviewed 84 FN episodes in children with malignancies treated between January 2017 and December 2021. Demographic and clinical data, initial and 72-hour antibiotic regimens, laboratory parameters (CRP, procalcitonin [PCT], interleukin-6 [IL-6], neutrophil-to-lymphocyte ratio [NLR]), blood culture results, length of hospital stay, and 30-day readmission were collected. Escalation was defined as a change to a broader-spectrum antibiotic within 72 hours. Logistic regression and comparative statistical tests were applied.Results: Escalation occurred in 27% (23/84) of FN episodes, most frequently from piperacillin-tazobactam to meropenem. Patients requiring escalation had significantly higher median CRP (115 vs. 62 mg/L, p=0.01), PCT (1.3 vs. 0.5 ng/mL, p=0.02), and IL-6 (120 vs. 65 pg/mL, p=0.04) levels. Blood culture positivity was more common in the escalation group (52% vs. 23%, p=0.01). NLR was higher in escalation cases (8.2 vs. 5.6), with borderline statistical significance (p=0.06). Median length of hospital stay was longer in escalation patients (10 vs. 7 days, p=0.02). Thirty-day readmission did not differ significantly between groups.Conclusions: Approximately one-quarter of FN episodes required antibiotic escalation within 72 hours. Elevated CRP, PCT, IL-6, and blood culture positivity were associated with escalation. These findings underscore the potential role of biomarkers in guiding early escalation decisions and optimizing antibiotic stewardship in pediatric FN.