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Sending fever and neutropenia home

October 19, 2016

Short Attention Span Summary

Send fever and neutropenia home?
I picked this study because it taught me not all patients with fever and neutropenia (FN) have the same risk.  My default is to admit all of them, but guidelines say that is not always needed.  The MASCC Score allows for risk stratification and even discharge on oral antibiotics for some patients with FN.  This study found that FN patients who were low risk were given overly aggressive treatment.  That is, they were admitted on IV antibiotics when they did not have to be.  This has implications for patients’ quality of life and for good antibiotic stewardship.

Spoon Feed
Until our oncologists specifically start telling me to do this, I plan to admit and give antibiotics IV.  But this study taught me there is another way to think about FN.  If this is news to you too, now we will be ready when and if onc starts doing this.  Journal Watch has a great free summary of this.




Abstract

Acad Emerg Med. 2016 Sep 9. doi: 10.1111/acem.13079. [Epub ahead of print]

ED Management of Patients with Febrile Neutropenia: Guideline Concordant or Overly Aggressive?

Baugh CW1, Wang TJ2, Caterino JM3, Baker ON4, Brooks GA5, Reust AC4, Pallin DJ4.

Author information: 

  • 1Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA. cbaugh@partners.org.
  • 2Harvard Medical School, Boston, MA.
  • 3Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
  • 4Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA.
  • 5Gastrointestinal Cancer Center, Dana Farber Cancer Institute, Boston, MA.

ABSTRACT

OBJECTIVES: 

The Infectious Diseases Society of America and the American Society of Clinical Oncology recommend risk stratification of patients with febrile neutropenia (FN), and discharge with oral antibiotics for low-risk patients. We studied guideline concordance and clinical outcomes of FN management in our ED.

METHODS: 

Our urban, tertiary-care teaching hospital provides all emergency and inpatient services to a large comprehensive cancer center. We performed a structured chart review of all FN patients seen in our ED from 01/2010-12/2014. Using electronic medical records, we identified all visits by patients with fever and an absolute neutrophil count <1000 cells/μL, and then included only patients without a clear source of infection. Following national guidelines, we classified patients as low- or high-risk, and assessed guideline concordance in disposition and parenteral vs. oral antibiotic therapy by risk category as our main outcome measure.

RESULTS: 

Of 173 qualifying visits, we classified 44 (25%) as low-risk and 129 (75%) as high-risk. Management was guideline-concordant in 121 (70%, 95%CI 63-77%). Management was guideline discordant in 43 (98%, 95%CI 88-100) of low-risk patients, versus 9 (7%, 95%CI 3-13) of high-risk patients (relative risk [RR] 14, 95%CI 7.5-26). Of 52 guideline-discordant cases, 36 (83%, 95%CI 72-93) involved low-risk cases with treatment that was more aggressive than recommended.

CONCLUSIONS: 

Guideline concordance was low among low-risk patients, with management tending to be more aggressive than recommended. Unless data emerge that undermine the guidelines, we believe that many of these hospitalizations and parenteral antibiotic regimens can be avoided, decreasing the risks associated with hospitalization, while improving antibiotic stewardship and patient comfort. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27611638 [PubMed – as supplied by publisher]