Getting It Right the First Time: Improving Antibiotic Stewardship in Febrile Oncology Patients Presenting to the Pediatric Emergency Department

PURPOSE: Febrile pediatric oncology patients with central lines are at high risk of sepsis. However, emerging evidence fails to support the historic 1-hour window for antibiotic administration in well-appearing patients, suggesting that providers may have more time to tailor antibiotic therapy in these patients. Before this quality improvement project, 92% of febrile oncology patients without severe neutropenia (absolute neutrophil count [ANC] ≥500) in our pediatric emergency department (ED) received empiric intravenous cefepime. The aim of this study was to decrease this percentage to 60% by June 30, 2025. METHODS: A multidisciplinary team implemented interventions using Plan-Do-Study-Act (PDSA) methodology, including clinical pathways and order set updates, tips for communicating with families, and a risk stratification tool. The outcome measure was the percentage of febrile oncology patients without severe neutropenia who received cefepime. Process measures included order set use, percentage of antibiotics ordered before ANC results were obtained, and the time to ANC result. Balancing measures included readmission of patients within 7 days, admission to the intensive care unit within 24 hours of ED discharge, and percentage of patients with antibiotics administered >3 hours after arrival. RESULTS: There was an average of 7.9/month febrile oncology patients without severe neutropenia. Following the first PDSA cycle, cefepime use in patients without severe neutropenia decreased from 92% to 26.8%. Patients with antibiotics administered before ANC reporting decreased from 90% to 35.2%. Patients with IV antibiotics administered >3 hours from arrival increased from 2.3% to 29%. Remaining balancing measures did not statistically change. CONCLUSION: Implementation of a new clinical pathway with order sets, adoption of a risk stratification tool, and patient and family involvement safely improved antibiotic stewardship for febrile oncology patients.