There is no place like home. Part 1. The Australian Predicting Infectious Complications in Children with Cancer (PICNICC) Project Part 2. National Scale Up of the Low Risk Febrile Neutropenia Program

In part 1 of of this study, the aim is to prospectively validate nine clinical decision rules (CDRs) including the European-based PICNICC CDR, that stratify children with cancer and febrile neutropenia into low and high risk for microbiologically documented infection (MDI), so as to optimise their management and quality of life and improve resource allocation. The PICNICC CDR is based on five simple clinical variables including (i) tumour type (ii) maximum temperature, (iii) total white cell count, (iv) monocyte count, (v) haemoglobin and (vi) severity of illness. It provides the opportunity for a world first external validation of this globally derived rule and is a critical step before the rule can be safely implemented into practice. In Part 1 and 2 of the study, patient demographic, FN episode and outcome data at day 0, completion of the FN episode and day 30 will be collected prospectively by the study-site research assistant/nurse (RA/RN) according to international consensus definitions. Patients that develop FN outside of RA/RN working hours will have relevant data collected retrospectively within 72 hours. Data will be entered into an electronic password protected study database (REDCap). Accuracy of data collection will be verified by project manager (first ten records for each site then periodically throughout recruitment) as well as chief investigator and site associate investigator. For patient recruited only in part 1 of this study, novel biomarkers that predict outcomes will be identified using RNA sequencing (RNAseq) analysis on peripheral blood mononuclear cells (PBMC) collected from participants at Royal Children's Hospital Melbourne at two time points. Blood will be collected in EDTA tubes (5ml if <40kg and 12ml if >40kg). Peripheral blood samples will be processed by the Children’s Cancer Centre Tissue Bank. Within two hours of sample collection, plasma will be harvested following centrifugation and stored at -80 degrees celsius. PBMCs will be isolated by Ficoll density gradient centrifugation. PBMC will be cryopreserved and stored in the vapor phase of liquid nitrogen for in vitro assays and pelleted and resuspended in RNAlater for nucleic acid extraction. Samples will be batched and distributed by the CCC Tissue Bank. RNAseq will be performed at MCRI (25-30 M coverage) on unstimulated and stimulated samples. Additionally PBMCs will be analysed by flow cytometry to determine the frequency of T cells, and monocytes. This latter data set will allow bioinformatic deconvolution to dissect the transcriptome of relevant cell types. When we have established which method (stimulated or unstimulated) provides that most robust data we will proceed to collect and analyses 100-200 samples . Flow cytometry and stimulation of PBMCs will be performed in the Pellegrini laboratory at the Walter and Eliza Hall Institute of Medical Research. The cell samples sent to WEHI will be thawed and placed in culture medium. During the pilot study these samples will be unstimulated or stimulated with agents that are known to amplify immune responses for a few hours. The medium the cells were kept in will then be collected, to be analysed upon completion of transcriptome analysis for secreted immunogenic factors. The cells themselves will be labelled with specific antibodies which will distinguish the individual cells into subtypes of immune cells and their activation status. During this process all the cells will be run on a machine to analyse composition. Therefore no cells will remain after the analysis has taken place. However, the culture medium these cells were kept in will be stored indefinitely at -80 degrees celsius in the secure Pellegrini laboratory freezer. RNA sequencing is being carried out to identify biomarkers that can predict the outcome of FN episodes only. The transcriptome analysis performed as part of this study is purely exploratory. None of the tests being performed are validated or accredited as diagnostics. Therefore no information will be revealed about disease-predisposing germline traits, heritable disorders or parental identity. To investigate the cost of patient in hospital versus patients managed at home, all consented patients will be reviewed for their cost information using hospital costs records for inpatient data and outpatient costs via the Medicare consent form, completed at patient recruitment by the RA. The optional quality of life surveys have been replicated into an electronic format for consented parents/guardians and patients older than three years, The age ranges for the CHU-9D assessment (7 to 18 years and a proxy version for patients aged 3 to 6 years) have been stipulated by the University of Sheffield and will be adhered to when implementing the questionnaire. The RA will implement each tool electronically prior to discharge, providing education on how to complete the surveys. To provide a comprehensive overview of the true impact of FN and unplanned hospital admission on the child. For patients that have been discharged home, the surveys will be distributed electronically, via RedCAP, to valid email address. In part 2 of the study, we will be evaluating the implementation process and the clinical, quality of life and economic impact of the low risk FN program across 8 hospitals in Australia. The Consolidated Framework for Implementation Research (CIFR) will be used (https://cfirguide.org/) to guide implementation and evaluation. This will be completed as a survey by the healthcare professionals. In addition, each site will have regular focus group meetings to review implementation processes for each site. Outcomes from these meetings will be reported back to the central management team for their review and consideration. In summary, low risk febrile neutropenia patients will continued to be recruited as per Part 1, with the same frequency/duration of participation. The focus for Part 2 of the study will be on the hospitals and healthcare professionals implementing the low risk febrile neutropenia program at their site. Furthermore, we will continue to obtain Medicare data from patients to evaluate cost of patients at home versus patients staying in hospital.