Pediatr Blood Cancer 2014;61:680–686 Predictors of Wait-Time for Antibiotic Initiation and Association of Wait-Time With Hospital Length of Stay And ICU Admission Among Children With Cancer at the Southern Philippines Medical Center Jeannette Kirby, DPh, 1 Mae Dolendo, MD, 2 Don Guimera, BSN, RN, CIC, 3 Czarina Castillo, RN, 2 Kyle M. Johnson, PhD, 3 Fawaz Mzayek, MD, MPH, PhD, 1 Vikki G. Nolan, DSc, Msc, 1 George Relyea, MA, MS, 1 and Miguela A. Caniza, MD 3,4,5 * INTRODUCTION Infection is a medical emergency in cancer [1] that can progress to septic shock in neutropenic patients if broad-spectrum antibiotic therapy is delayed [2,3]. Similarly, outcomes can be devastating in non-immunocompromised patients with severe infections if the wait-time for antibiotics is prolonged [4]. Infecting pathogens range from those circulating in the community [5] to multidrug- resistant and opportunistic microorganisms [6]. The timing of antibiotic administration depends, in part, on where the infectious symptom begins; when it arises at home, the caregivers’ knowledge is essential in expediting care; when it arises at the hospital, the determining factors are institutional work flow [7], teamwork [8], appropriate staffing [9], clinicians’ knowledge [10], and work load [11]. In the Philippines, as in other low- and middle- income countries, childhood cancer treatment is deficient and survival is suboptimal [12] compared with that in high-income countries, where long-term survival of patients with certain malignancies is as high as 80% [13]. Approximately 4,600 new cases of pediatric cancer are diagnosed each year in the Philippines [14]. The survival of these patients depends on rapid intervention when oncologic emergencies such as infection arise [3,15]. Few studies have assessed the factors involved in prolonged antibiotics wait-time (AWT) in low- and middle-income coun- tries [16–18]. Identifying and addressing such factors may reduce AWT, hospital length of stay (LOS), and rate of intensive care unit (ICU) admission. Total AWT (TAWT) includes the time period of emergence of symptoms attributed to an infection before patient arrival to the hospital plus the time that elapses after patient arrival until the provision of the first dose of antibiotics. This study identified predictors of prolonged TAWT and determined the relationship of TAWT to LOS and the risk of ICU admission at the Southern Philippines Medical Center (SPMC). METHODS Study Design and Population Patients’ records were reviewed retrospectively; and health care providers were surveyed at the Children’s Cancer and Blood Disease Unit of the SPMC. Admissions of patients 18 years or younger who received at least one dose of antibiotic for suspected infection between January 1 and June 30, 2011 were included in the Background. Expedited antibiotic administration improves the survival of children with cancer and infection. A 1-hour antibiotic wait-time (AWT) post-hospital arrival is a quality-of-care benchmark in healthcare. However, multiple factors preclude achieving this goal in developing countries. Predictors of AWT and its association with hospital length of stay (LOS) and intensive care unit (ICU) admission at the Southern Philippines Medical Center (SPMC) were identified. Procedures. Health and socioeconomic characteristics of 55 children in 92 admissions who required antibiotics were reviewed; and SPMC care providers about institutional capacity and response to suspected infection were surveyed. Results. The mean total AWT was 3 days and 15 hours. For admissions of established patients, mean total AWT and mean LOS were approximately half that for new patients. Admissions from high-income households waited an average 44% less for antibiotics and were discharged 43% sooner than those from medium-income households. Admissions from residence owner families waited 31% less to receive antibiotics, and total AWT for admissions of patients with no insurance was 32% less than for those with insurance. The likelihood of ICU admission increased 20% with every 1-day increase in total AWT (95% CI: 1.02 1.42). Only 59% of nurses recognized fever as an emergency. Conclusions. AWT is complex and multifactorial; it may be reduced by educating parents and care providers about infection and infection control and improving the availability of antibiotics and associated supplies. These interventions will most likely reduce ICU admissions and possibly LOS and increase the survival of pediatric oncology patients at SPMC. Pediatr Blood Cancer 2014;61:680–686. # 2013 Wiley Periodicals, Inc. Key words: antibiotic; developing country; infection; low-middle income country; neutropenia; pediatric cancer; Philippines Additional supporting information may be found in the online version of this article at the publisher’s web-site. 1 School of Public Health, University of Memphis, Memphis, Tennessee; 2 Children’s Cancer and Blood Disease Unit of the Southern Philippines Medical Center, Davao City, Philippines; 3 Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee; 4 International Outreach Program, St. Jude Children’s Research Hospital, Memphis, TN; 5 Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee Grant sponsor: American Lebanese Syrian Associated Charities (ALSAC) Conflict of interest: Nothing to declare. This work was presented as a poster at the Association for Professionals in Infection Control and Epidemiology 2012 Annual Conference and International Meeting in San Antonio, Texas, June 4–6, 2012.  Correspondence to: Miguela A. Caniza, Department of Infectious Diseases, Mail Stop 721, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678. E-mail: miguela.caniza@stjude.org Received 2 July 2013; revised form 2 October 2013; Accepted 2 October 2013  C 2013 Wiley Periodicals, Inc. DOI 10.1002/pbc.24836 Published online 25 November 2013 in Wiley Online Library (wileyonlinelibrary.com).