Management of fever in neutropenic patients with different risks of complications

Essential Review of Oncological Emergencies

Innovations in oncology have expanded treatment eligibility, leading to a rise in cancer patients requiring critical care. This necessitates that all critical care clinicians possess a fundamental knowledge of prevalent oncological conditions and identify emergent scenarios requiring immediate action. This article will explore key oncological complications and their management approaches.

On-body injector pegfilgrastim for chemotherapy-induced neutropenia prophylaxis: Current Status

INTRODUCTION

Myelosuppression, a challenge in cancer treatment, often results in severe complications. Prophylactic granulocyte colony-stimulating factors, particularly pegfilgrastim, mitigate chemotherapy-induced neutropenia. This narrative review evaluates the role of on-body injector (OBI) devices for pegfilgrastim administration. A comprehensive search strategy of PubMed and AI-powered intuitive search tools, complemented by authors' contributions, yielded a body of papers presenting evidence on OBI devices, their effectiveness and safety, the benefits and challenges of OBI versus pre-filled syringe administration, patient preferences for pegfilgrastim administration, and economic considerations.

DISCUSSION

OBI devices prove effective and safe, with advantages such as reduced clinic visits and enhanced adherence. Studies highlight cost-efficiency and expanded access, emphasizing the socioeconomic context. Patient and provider preferences underscore the potential of OBI devices in cancer care, with implications for healthcare resource utilization and pharmacoeconomics.

CONCLUSION

The value proposition of OBI devices lies in improving patient outcomes, convenience, resource optimization, and enhancing the overall cancer care experience. As biosimilar OBIs enter the market, they may offer cost savings, further influencing their adoption and their positioning as a cost-efficient alternative in cancer care. Ongoing research and technological advancements are expected to contribute to the broader acceptance of OBI devices in cancer care delivery.

The diagnostic utility of computed tomography scans performed for febrile neutropenia in a single centre

BACKGROUND

Computed tomography (CT) imaging has become a first line investigation for most cases of febrile neutropenia (FN) which can be the only sign of infection in oncology patients undergoing active chemotherapy and bone marrow transplants. The utility of routine non-targeted imaging remains unclear.

OBJECTIVE

To assess and compare the diagnostic rate between targeted, non-targeted and pan-scan CT in identifying an acute source of infection in adult oncology patients with FN.

MATERIALS AND METHODS

A retrospective observational study was conducted between February 2019 and March 2023 on 417 consecutive CT examinations for the clinical indication of source identification in FN. Scans were noted for the anatomical regions that were imaged and reports were classified as positive, negative or equivocal for infection. Pre-existing pathology was also noted. Results were tabulated and statistical analyses for comparison between groups of scans was performed using chi-square test.

RESULTS

All targeted regional scans had statistically significant difference in positive rate compared to non-targeted scans of the respective region; chest (Χ²(1)=18.11, P<.001); sinus (Χ²(1)=15.36, P<.001); abdomen and pelvis (Χ²(1)=5.95, P=.01). Pneumonia (41.3 %) was much more likely to be the diagnosis compared to sinusitis (16.2 %) in concomitant CT chest to sinus examinations (Χ²(1)=45.3, P<.001). Pan-scans had a higher incidence of positive diagnosis compared to all-targeted scans (Χ²(1)=4.91, P=.03) but when compared to higher yield targeted scans (abdomen and chest), there was no statistical difference (Χ²(1)=2.43, P=.12). 20/54 patients had pan-scans despite having localising symptoms.

CONCLUSION

Imaging guided by presenting signs and symptoms can help to reduce unnecessary imaging and promote more judicious use of non-targeted and pan-scan CT in current practices.

Approach to febrile neutropenia in patients undergoing treatments for hematologic malignancies

Febrile neutropenia (FN) is common among hematologic malignancy patients, including recipients of hematopoietic cell transplantation (HCT) and cellular therapies such as chimeric antigen receptor (CAR)-T-cell therapy. Prompt empiric antibiotic use has been the mainstay for decades but a "one-size-fits-all" approach is no longer broadly accepted, as treatment-related infectious risk are more understood. Growing antimicrobial resistance is an increasing clinical challenge. Evolving strategies on de-escalation of broad-spectrum antibiotics in FN without identified infection are areas of particular interest.

Point of care thoracic ultrasound versus chest computed tomography in the approach of febrile neutropenia patients: A diagnostic accuracy cohort study

Single-center prospective cohort diagnostic accuracy study. Our study aimed to evaluate the accuracy and reproducibility of Thoracic Ultrasound (TUS) in detecting pulmonary pathology in immunosuppressed patients. We conducted a single-center prospective study. Consecutive patients with febrile neutropenia who underwent CT (Computerized Tomography) underwent TUS evaluation within 24h of CT. Both studies were performed by an expert who was blinded to the clinical information and results of the alternative imaging modalities. 34 patients met the inclusion criteria. The median age was 39.9 years (±17 standard deviation). TUS as a diagnostic test had a sensitivity of 92.9% and specificity of 83.3%, negative predictive value of 71.4%, and positive predictive value of 96.3%. Substantial between-method agreement was demonstrated with a kappa of 0.71 (P = .001) between the TUS and chest CT findings. We obtained a kappa of 1 (P = .001) for the final diagnosis of Pleural Effusion (PE). We concluded that TUS is a promising screening test for immunocompromised individuals. The results showed good diagnostic performance of TUS compared to CT for the detection of pulmonary findings highly suggestive of pathology with high accuracy and reproducibility.

Pegfilgrastim for the management of neutropenia during neoadjuvant chemotherapy with docetaxel, cisplatin, and 5-fluorouracil in esophageal cancer patients

BACKGROUND

Neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy is a new standard for locally advanced esophageal squamous cell carcinoma. The optimal timing of pegfilgrastim with the DCF regimen to prevent febrile neutropenia (FN) remains controversial. The effectiveness of concomitant pegfilgrastim administration with continuous 5-fluorouracil (5-FU) infusion in the DCF regimen was therefore assessed.

METHODS

All patients who received neoadjuvant DCF for esophageal cancer were retrospectively assessed. Patients who had been scheduled to receive pegfilgrastim on days 3-5 (early group) or days 7-9 (regular group) of the DCF regimen were included. Uni- and multivariate analyses were used to assess risk factors for FN.

RESULTS

Eighty-eight patients were included in the analysis. The 26 patients in the early group received pegfilgrastim as scheduled. In the 62 patients of the regular group, 51 received pegfilgrastim at a median of 7 days after starting DCF chemotherapy. However, 11 patients in the regular group could not receive pegfilgrastim. Twenty-two patients of the regular group and 2 patients of the early group developed FN after the first session of DCF. Early administration of pegfilgrastim and grade 4 neutropenia were significantly associated with onset of FN, with multivariate analysis identifying early administration of pegfilgrastim as an independent preventive factor and grade 4 neutropenia as a risk factor, after adjusting for sex and age.

CONCLUSION

Early pegfilgrastim administration is a safe approach that reduces the incidence of FN in DCF therapy. Using pegfilgrastim with continuous 5-FU infusion in the DCF regimen represents a reasonable option to prevent FN.

Efficacy of an antimicrobial stewardship intervention for early adaptation of antibiotic therapy in high-risk neutropenic patients

BACKGROUND

The 4th European Conference on Infections in Leukemia recommends early adaptation of empirical antibiotic therapy (EAT) for febrile neutropenia in stable patients.

OBJECTIVES

To assess the efficacy of an antimicrobial stewardship (AMS) intervention promoting early de-escalation and discontinuation of EAT in high-risk neutropenic patients.

METHODS

This before-after study was conducted in the hematology department of the University Hospital of Nice, France. The AMS intervention included the development of clinical decision support algorithms, a twice-weekly face-to-face review of all antibiotic prescriptions and monthly feedback on the intervention. The primary endpoint was overall antibiotic consumption during hospital stay, expressed as days of therapy (DOT).

RESULTS

A total of 113 admissions were included: 56 during the pre-intervention period and 57 during the intervention period. Induction chemotherapy and conditioning for allogeneic stem cell transplantation were the most frequent reasons for admission. In the intervention period, there was a significant decrease in overall antibiotic consumption (median DOT 20 vs. 28 days, p = 0.006), carbapenem consumption (median DOT 5.5 vs. 9 days, p = 0.017) and anti-resistant Gram-positive agents consumption (median DOT 8 vs. 11.5 days, p = 0.017). We found no statistical difference in the rates of intensive care unit admission (9% in each period) and 30-day mortality (5% vs. 0%, p = 0.243). Compliance with de-escalation and discontinuation strategies was significantly higher in the intervention period (77% vs. 8%, p < 0.001).

CONCLUSION

A multifaceted AMS intervention led to high compliance with early de-escalation and discontinuation of EAT and lower overall antibiotic consumption, without negatively affecting clinical outcomes.

Early Antibiotic Deescalation and Discontinuation in Patients with Febrile Neutropenia after Cellular Therapy: A Single-Center Prospective Unblinded Randomized Trial

The optimal duration of empiric antimicrobial therapy of febrile neutropenia in patients after cellular therapy is unclear. Early deescalation has been suggested by some authorities; however, data are lacking for cellular therapy recipients. We performed a randomized controlled study of cellular therapy recipients with febrile neutropenia to evaluate the safety and noninferiority of an early deescalation and discontinuation antibiotic strategy (EDD arm) versus standard broad-spectrum antibiotic treatment until recovery of neutropenia (standard duration arm). The primary outcome was the fraction of antibiotic-free neutropenia days. We randomized 110 patients to the standard duration arm (n = 51) or EDD arm (n = 59). The fraction of antibiotic-free neutropenia days was higher in the EDD arm compared to the standard duration arm (median, .8 [interquartile range (IQR), .62 to .86] versus .51 [IQR, .17 to .86]; P = .016). This was true for the per-protocol, allogeneic hematopoietic cell transplantation (HCT), autologous HCT, and anti-CD19 chimeric antigen receptor T cell therapy subgroups. Treatment success rate, subsequent fever, death within 30 days, and other common cellular therapy-related toxicities were all similar between the 2 study arms. An EDD antibiotic strategy in patients after cellular therapy was safe and associated with a substantial reduction in broad-spectrum antibiotic utilization without compromising cellular therapy outcomes.

Evaluation of Febrile Neutropenia in Hospitalized Patients with Neoplasia Undergoing Chemotherapy

Febrile neutropenia (FN) is a common but serious complication encountered in patients with cancer and is associated with significant morbidity and mortality. In this prospective study, 63 patients with solid tumors under chemotherapy or immunotherapy were admitted to the hospital due to febrile neutropenia, confirmed through clinical or microbiological documentation. The aim of this study was to provide a comprehensive overview of the epidemiological and microbiological characteristics of hospitalized neutropenic patients with solid tumors undergoing treatment. Additionally, we aimed to assess the duration of neutropenia and identify factors influencing patient outcomes. The median age of patients was 71 ± 10.2 years, most of which were males (66.7%), and the primitive tumor location was the lung (38.1%), with most patients (82.5%) being at disease stage IV. The median duration of neutropenia was three days (range 1-10), and, notably, mucositis was significantly associated with neutropenia lasting ≥3 days (p = 0.012). Patients with lung cancer (38.1%) and patients with stage IV disease (82.5%) presented a higher risk of FN, although these differences did not reach statistical significance. The site of infection was identifiable in 55.6% of patients, with positive cultures detected in 34.9% and positive blood cultures (BC) drawn in 17.5% of cases. Gram-positive bacteria were the predominant causative agents in BC (63.6%), with Staphylococci being the most prevalent among them (66.7%). The median duration of hospitalization was nine days (range, 3-43 days), and most patients showed improvement or cure of infection (16.9% and 74.6%, respectively). Among recorded risk factors, the Eastern Cooperative Oncology Group (ECOG) performance status (PS) appears to be statistically significant. Patients with an impaired PS score (2-4) experienced worse outcomes and higher likelihood of mortality (p = 0.004). Regarding the outcome, a longer duration of neutropenia was also statistically significant (p = 0.050). Of the patients, 12.7% ultimately succumbed to their conditions, with 37.5% attributed to infections. FN is a common yet serious complication in solid tumor patients. Adequate knowledge of the predictors of mortality and the microbiological causes are of utmost importance to allow accurate diagnosis and prompt treatment as they significantly influence patient outcomes.

Prevalence of blood stream infections and associated factors among febrile neutropenic cancer patients on chemotherapy at Ocean Road Cancer Institute, Tanzania

BACKGROUND

Febrile Neutropenia (FN) caused by bacteria in cancer patients is associated with poor prognosis. The aim of this study was to determine the prevalence of FN and associated factors among cancer patients on chemotherapy at Ocean Road Cancer Institute (ORCI), Tanzania.

METHODS

A cross-sectional study was conducted from June to September 2019. Study participants were conveniently recruited. A desk review of participants medical records was performed. Standard microbiological procedures used to culture and identify the bacterial isolates from the positive blood cultures of participants that presented with FN. Kirby-Bauer disc diffusion was used to perform the antibiotics susceptibility testing. SPSS version 20.0 and MS Excel were used in data entry and analysis. Chi-Square was used as a measure of association between various factors and neutropenia. P-value less than 0.05 was considered statistically significant.

RESULTS

A total 213 participants were enrolled. Of these 76.1% were female. Most of the participants came from the Coast region. Majority of participants presented with breast Cancer (36.2%) and GIT (20.2%). The prevalence of FN and bacteremia was 5.6% and 35.3% respectively. Staphylococcus Aureus (60%) and Coagulase-Negative Staphylococci (40%) were the main isolates. Of the 6 isolates tested most were resistant to Co-Trimoxazole 4/6 (66.7%) and Doxycycline 3/6 (50%). FN was positively associated with chemotherapy regimen (P = 0.0001), platelets count (P = 0.0001) and use of G-CSF (P = 0.0001).

CONCLUSION

The prevalence of FN among the cancer patients on chemotherapy in Tanzania is low but associated with drug-resistant bacteria.

The Risk of Rectal Temperature Measurement in Neutropenia

BACKGROUND

Avoiding rectal thermometry is recommended in patients with neutropenic fever. Permeability of the anal mucosa may result in a higher risk of bacteremia in these patients. Still, this recommendation is based on only a few studies.

METHODS

This retrospective study included all individuals admitted to our emergency department during 2014-2017 with afebrile (body temperature <38.3°C) neutropenia (neutrophil count <500 cells/microL) who were over the age of 18. Patients were stratified by the presence or absence of a rectal temperature measurement. The primary outcome was bacteremia during the first five days of index hospitalization; the secondary outcome was in-hospital mortality.

RESULTS

The study included 40 patients with rectal temperature measurements and 407 patients whose temperatures were only measured orally. Among patients with oral temperature measurements, 10.6% had bacteremia, compared to 5.1% among patients who had rectal temperature measurements. Rectal temperature measurement was not associated with bacteremia, neither in non-matched (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.07-1.77) nor in matched cohort analyses (OR 0.37, 95% CI 0.04-3.29). In-hospital mortality was also similar between the groups.

CONCLUSIONS

Patients with neutropenia who had their temperature taken using a rectal thermometer did not experience a higher frequency of events of documented bacteremia or increased in-hospital mortality.

Characterization of Febrile Neutropenia Management in Children With Malignancies: A Single-Center Evaluation

OBJECTIVE

Current recommendations for febrile neutropenia (FN) include initiation of broad-spectrum antibiotics without clear indications of when or how to de-escalate or target therapy, especially in those without microbiologically defined bloodstream infections (MD-BSIs). The purpose of this study is to characterize a pediatric FN population, FN management, and identify the proportion of patients with MD-BSI.

METHODS

This study was a single-center, retrospective chart review of patients admitted to the University of North Carolina Children's Hospital between January 1, 2016, and December 31, 2019, with a diagnosis of FN.

RESULTS

There were 81 unique encounters included in this study. MD-BSI was the etiology of fever in 8 FN episodes (9.9%). The most common empiric antibiotic regimen was cefepime (62%) followed by cefepime and vancomycin (25%). The most common de-escalation type was the discontinuation of vancomycin (83.3%), and the most common type of escalation was the addition of vancomycin (50%). The median antibiotic total duration in patients without MDI-BSI was 3 days (IQR, 5-9).

CONCLUSIONS

In this single-center, retrospective review, most FN episodes were not due to an MD-BSI. There were inconsistencies in practice of when discontinuation of antibiotic therapy occurred in patients without MD-BSI. De-escalation or cessation of antibiotic therapy before neutropenia resolution did not result in any documented complication. These data suggest a role for implementing an institutional guideline to improve consistency in antimicrobial use in pediatric patients with febrile neutropenia.

Clinical and microbiological profiles in post-chemotherapy neutropenic fever in hematological malignancy: exploration of clinical phenotype patterns by two-step cluster analysis

BACKGROUND

Epidemiology of infectious diseases causing febrile illness varies geographically with human attributes. Periodic institutional surveillance of clinical and microbiological profiles in adding data to updating trends, modulating pharmatherapeutics, signifying possible excessive treatments and risk of drug resistance in post-chemotherapy neutropenic fever (NF) in hematological malignancy (HM) is limited. We aimed to review institutional clinical and microbiological data and explore clinical phenotype pattern groups among data.

METHODS

Available data from 372 NF episodes were included. Demographics, types of malignancies, laboratory data, antimicrobial treatments and febrile-related outcome data such as predominant pathogens and microbiological diagnosed infections (MDIs) were collected. Descriptive statistics, two-step cluster analysis and non-parametric tests were employed.

RESULTS

The occurrences of microbiological diagnosed bacterial infections (MDBIs; 20.2%) and microbiological diagnosed fungal infections (MDFIs; 19.9%) were almost equal. Gram-negative pathogens (11.8%) were comparable with gram-positive pathogens (9.9%), with gram-negative being slightly predominant. Death rate was 7.5%. Two-step cluster analysis yielded four distinct clinical phenotype pattern (cluster) groups: cluster 1 'lymphomas without MDIs', cluster 2 'acute leukemias MDBIs', cluster 3 'acute leukemias MDFIs' and cluster 4 'acute leukemias without MDIs'. Considerable NF events with antibiotic prophylaxis being not identified as MDI might have cases in low-risk with non-infectious reasons causing febrile reactions that might possibly not require prophylaxis.

CONCLUSIONS

Regular institutional surveillance with active parameter assessments to signify risk levels in the post-chemotherapy stage, even prior to the onset of fever, might be an evidence-based strategy in the management of NF in HM.

Population pharmacokinetic model and dosing optimization of vancomycin in hematologic malignancies with neutropenia and augmented renal clearance

AIM

Data on the pharmacokinetics (PK) and area under the curve (AUC)-based dosing strategy of vancomycin (VCM) in hematologic malignancies are limited. According to our preliminary narrative review, only a few population PK analyses in hematologic malignancies have been performed. Therefore, we aimed to develop a population PK model, investigate the factors influencing VCM PK, and propose an optimal dosing regimen for hematologic malignancies.

METHODS

A retrospective study was conducted in patients with underlying hematologic malignancies treated with VCM. A total of 148 patients were enrolled for population PK modeling. Simulation analyses were performed to identify dosing regimens achieving a target exposure of AUC_0-24 of 400-600 mg h/L at the steady-state.

RESULTS

The VCM PK data were best described with a one-compartment model. Significant covariates included creatinine clearance (Ccr), diagnosis of acute myeloid leukemia (AML) and neutropenia on VCM clearance (CL), and body weight (WT) on the volume of distribution (Vd). The typical values of CL and Vd were 3.09 L/h (normalized to Ccr value of 90 mL/min) and 122 L/70 kg, respectively. Concerning the effect on VCM dosing, AML patients required 15% higher doses than non-AML patients, independently of renal function. In contrast, for neutropenic patients, only those with augmented renal clearance (ARC, Ccr value ≥ 130 mL/min) required a 10% dose increase compared to non-neutropenic patients.

CONCLUSION

AML patients with neutropenia and ARC represent a critical population with a higher risk of VCM underexposure. Thus, individualized dosing adjustment and therapeutic drug monitoring are strongly recommended.

Challenges and Opportunities in Antimicrobial Stewardship among Hematopoietic Stem Cell Transplant and Oncology Patients

Antimicrobial stewardship programs play a critical role in optimizing the use of antimicrobials against pathogens in the era of growing multi-drug resistance. However, implementation of antimicrobial stewardship programs among the hematopoietic stem cell transplant and oncology populations has posed challenges due to multiple risk factors in the host populations and the infections that affect them. The consideration of underlying immunosuppression and a higher risk for poor outcomes have shaped therapeutic decisions for these patients. In this multidisciplinary perspective piece, we provide a summary of the current landscape of antimicrobial stewardship, unique challenges, and opportunities for unmet needs in these patient populations.

Impact of COVID-19 Related Restrictions on Infections in Children with Cancer or after Hematopoietic SCTA

BACKGROUND

Infections are a major concern for immunocompromised children. We investigated whether non-pharmaceutical interventions (NPIs) implemented in the general population during the coronavirus disease 2019 (COVID-19) pandemic in Germany had an impact on frequency, type and severity of infections in these patients.

PATIENTS AND METHODS

We analyzed all admissions to the clinic of pediatric hematology, oncology and stem cell transplantation (SCT) with (suspected) infection or fever of unknown origin (FUO) from 2018 to 2021.

RESULTS

We compared a 27-month period before NPIs (Pre-COVID: 01/2018-03/2020; 1041 cases) with a 12-month period with underlying NPIs (COVID: 04/2020-03/2021; 420 cases). During the COVID period the number of in-patient stays with FUO or infections decreased (38,6 cases/month vs. 35,0 cases/month), the median duration of hospital stays was longer (8 d (CI95: 7-8 d) vs. 9 d (CI95: 8-10 d) P=0,02)), the mean number of antibiotics per case increased (2,1 (CI95: 2,0-2,2) vs. 2,5 (CI95: 2,3-2,7); P=0,003)) and a substantial reduction of viral respiratory and gastrointestinal infections per case was seen (0,24 vs. 0,13; P<0,001). Notably, there was no detection of respiratory syncytial virus, influenza and norovirus, between May 2020 and March 2021. Based on need of intensive care measures and further parameters we conclude that severe (bacterial) infections were not significantly reduced by NPIs.

CONCLUSIONS

Introduction of NPIs in the general population during the COVID-pandemic substantially reduced viral respiratory and gastrointestinal infections in immunocompromised patients, while severe (bacterial) infections were not prevented.

Pre-emptive antifungal therapy versus empirical antifungal therapy for febrile neutropenia in people with cancer

BACKGROUND

Intensive cytotoxic chemotherapy for people with cancer can cause severe and prolonged cytopenia, especially neutropenia, a critical condition that is potentially life-threatening. When manifested by fever and neutropenia, it is called febrile neutropenia (FN). Invasive fungal disease (IFD) is one of the serious aetiologies of chemotherapy-induced FN. In pre-emptive therapy, physicians only initiate antifungal therapy when an invasive fungal infection is detected by a diagnostic test. Compared to empirical antifungal therapy, pre-emptive therapy may reduce the use of antifungal agents and associated adverse effects, but may increase mortality. The benefits and harms associated with the two treatment strategies have yet to be determined.  OBJECTIVES: To assess the relative efficacy, safety, and impact on antifungal agent use of pre-emptive versus empirical antifungal therapy in people with cancer who have febrile neutropenia.

SEARCH METHODS

We searched CENTRAL, MEDLINE Ovid, Embase Ovid, and ClinicalTrials.gov to October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared pre-emptive antifungal therapy with empirical antifungal therapy for people with cancer.

DATA COLLECTION AND ANALYSIS

We identified 2257 records from the databases and handsearching. After removing duplicates, screening titles and abstracts, and reviewing full-text reports, we included seven studies in the review. We evaluated the effects on all-cause mortality, mortality ascribed to fungal infection, proportion of antifungal agent use (other than prophylactic use), duration of antifungal use (days), invasive fungal infection detection, and adverse effects for the comparison of pre-emptive versus empirical antifungal therapy. We presented the overall certainty of the evidence for each outcome according to the GRADE approach.

MAIN RESULTS

This review includes 1480 participants from seven randomised controlled trials. Included studies only enroled participants at high risk of FN (e.g. people with haematological malignancy); none of them included participants at low risk (e.g. people with solid tumours).  Low-certainty evidence suggests there may be little to no difference between pre-emptive and empirical antifungal treatment for all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.72 to 1.30; absolute effect, reduced by 3/1000); and for mortality ascribed to fungal infection (RR 0.92, 95% CI 0.45 to 1.89; absolute effect, reduced by 2/1000). Pre-emptive therapy may decrease the proportion of antifungal agent used more than empirical therapy (other than prophylactic use; RR 0.71, 95% CI 0.47 to 1.05; absolute effect, reduced by 125/1000; very low-certainty evidence). Pre-emptive therapy may reduce the duration of antifungal use more than empirical treatment (mean difference (MD) -3.52 days, 95% CI -6.99 to -0.06, very low-certainty evidence). Pre-emptive therapy may increase invasive fungal infection detection compared to empirical treatment (RR 1.70, 95% CI 0.71 to 4.05; absolute effect, increased by 43/1000; very low-certainty evidence). Although we were unable to pool adverse events in a meta-analysis, there seemed to be no apparent difference in the frequency or severity of adverse events between groups. Due to the nature of the intervention, none of the seven RCTs could blind participants and personnel related to performance bias. We identified considerable clinical and statistical heterogeneity, which reduced the certainty of the evidence for each outcome. However, the two mortality outcomes had less statistical heterogeneity than other outcomes.

AUTHORS' CONCLUSIONS

For people with cancer who are at high-risk of febrile neutropenia, pre-emptive antifungal therapy may reduce the duration and rate of use of antifungal agents compared to empirical therapy, without increasing over-all and IFD-related mortality; but the evidence regarding invasive fungal infection detection and adverse events was inconsistent and uncertain.

Oncologic emergencies and urgencies: A comprehensive review

Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

Body temperature trends of critically Ill patients on continuous renal replacement therapy: A single-center retrospective study

BACKGROUND

Interpretation of human body temperature in patients on continuous renal replacement therapy (CRRT) is challenging. Clinicians currently use definitions of 'normal' temperature derived from healthy patients over a century ago and apply these definitions to patients on continuous renal replacement therapy (CRRT). There is a significant opportunity to refine temperature definitions to apply to the increasing population of critically ill patients on CRRT.

METHODS

A total of 1361 critically ill patients admitted to the hospital between 12/1/2006 and 11/31/2015 and requiring CRRT were studied. Temperature data were summarized (median, IQR) and compared during time periods that patients were on CRRT and time periods that they were not on CRRT using paired comparisons. Additionally, analyses were performed to compare temperature dynamics between patients who died during their hospitalization with those who did not.

RESULTS

The median body temperature change was -0.6 °C (95% CI -1.3, -0.6) from 12 h before CRRT to 12 h after CRRT (p < .001), and an increase of 0.6 °C (95% CI 0.2, 0.6) from 12 h before CRRT end to 12 h after CRRT end (p < .001). Temperature significantly increased by a median 0.3 °C from the start to the end of CRRT.

CONCLUSIONS

There are significant body temperature changes in critically ill patients on CRRT with cooling at the time of CRRT initiation and warming at the time of CRRT cessation.

A Novel Risk Predictive Scoring Model for Predicting Subsequent Infection After Carbapenem-Resistant Gram-Negative Bacteria Colonization in Hematological Malignancy Patients

Background

This study investigated the high-risk factors associated with the increased vulnerability for subsequent clinical CR-GNB infection in carbapenem-resistant Gram-negative bacteria (CR-GNB)-colonized hematological malignancy (HM) patients and built a statistical model to predict subsequent infection.

Method

All adult HM patients with positive rectoanal swabs culture for CR-GNB between January 2018 and June 2020 were prospectively followed to assess for any subsequent CR-GNB infections and to investigate the risk factors and clinical features of subsequent infection.

Results

A total of 392 HM patients were enrolled. Of them, 46.7% developed a subsequent clinical CR-GNB infection, with 42 (10.7%) cases of confirmed infection and 141 (36%) cases of clinically diagnosed infection. Klebsiella pneumoniae was the dominant species. The overall mortality rate of patients colonized and infected with CR-GNB was 8.6% and 43.7%. A multivariate analysis showed that remission induction chemotherapy and the duration of agranulocytosis, mucositis, and hypoalbuminemia were significant predictors of subsequent infection after CR-GNB colonization. According to our novel risk-predictive scoring model, the high-risk group were >3 times more likely to develop a subsequent infection in comparison with the low-risk group.

Conclusion

Our risk-predictive scoring model can early and accurately predict a subsequent CR-GNB infection in HM patients with CR-GNB colonization. The early administration of CR-GNB-targeted empirical therapy in the high-risk group is strongly recommended to decrease their mortality.

Biomarkers for Diagnosing Febrile Illness in Immunocompromised Children: A Systematic Review of the Literature

OBJECTIVE

This study aims to assess the performance of biomarkers used for the prediction of bacterial, viral, and fungal infection in immunocompromised children upon presentation with fever.

METHODS

We performed a literature search using PubMed and MEDLINE and In-Process & Other Non-indexed Citations databases. Cohort and case-control studies assessing biomarkers for the prediction of bacterial, viral, or fungal infection in immunocompromised children vs. conventional microbiological investigations were eligible. Studies including adult patients were eligible if pediatric data were separately assessable. Data on definitions used for infections, fever, and neutropenia and predictive values were collected. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

Fifty-two studies involving 13,939 febrile episodes in 7,059 children were included. In total, 92.2% were in cancer patients (n = 48), and 15.7% also included hematopoietic stem cell transplantation patients (n = 8). Forty-three biomarkers were investigated, of which 6 (CRP, PCT, IL-8, IL-6, IL-10, and TNFα) were significantly associated with bacterial infection at admission, studied in multiple studies, and provided predictive data. Literature on the prediction of viral and fungal infection was too limited. Eight studies compared C-reactive protein (CRP) and procalcitonin (PCT), with PCT demonstrating superiority in 5. IL-6, IL-8, and IL-10 were compared with CRP in six, four, and one study, respectively, with mixed results on diagnostic superiority. No clear superior biomarker comparing PCT vs. IL-6, IL-8, or IL-10 was identified.

DISCUSSION

There is great heterogeneity in the biomarkers studied and cutoff values and definitions used, thus complicating the analysis. Literature for immunocompromised children with non-malignant disease and for non-bacterial infection is sparse. Literature on novel diagnostics was not available. We illustrated the challenges of diagnosing fever adequately in this study population and the need for improved biomarkers and clinical decision-making tools.

OUP accepted manuscript

Background

The FEbrile Neutropenia after ChEmotherapy (FENCE) score was developed to estimate the risk of febrile neutropenia (FN) at first cycle of chemotherapy but has not been externally validated. We aimed to validate the FENCE score based on its risk groups in patients treated at a comprehensive cancer center.

Methods

We conducted a retrospective study of treatment-naïve adult patients with solid tumors and diffuse large B-cell lymphoma who received first-cycle chemotherapy between January and November 2019. Patients were followed until the second cycle of chemotherapy to identify any FN events (neutrophil count <0.5 × 10⁹/L with fever ≥38.2°C). The FENCE score was determined and patients classified as low, intermediate, high, and very high risk. The discriminatory ability of classifying patients into FENCE risk groups was calculated as the area under the receiver operating characteristics curve and incidence rate ratios within each FENCE risk group.

Results

FN was documented during the first cycle of chemotherapy in 45 of the 918 patients included (5%). The area under the receiver operating characteristics curve was 0.66 (95% confidence interval [CI] = 0.58 to 0.73). Compared with the low-risk group (n = 285), the incidence rate ratio of developing FN was 1.58 (95% CI = 0.54 to 5.21), 3.16 (95% CI = 1.09 to 10.25), and 3.93 (95% CI = 1.46 to 12.27) in the intermediate (n = 293), high (n = 162), and very high (n = 178) risk groups, respectively.

Conclusions

In this study, classifying patients into FENCE risk groups demonstrated moderate discriminatory ability for predicting FN. Further validation in multicenter studies is necessary to determine its generalizability.

Safety & efficacy of antibiotic de-escalation and discontinuation in high-risk haematological patients with febrile neutropenia: a single-centre experience

Background

There is currently no consensus on optimal duration of antibiotic treatment in febrile neutropenia. We report on the clinical impact of implementation of antibiotic de-escalation and discontinuation strategies based on the Fourth European Conference on Infections in Leukaemia (ECIL-4) recommendations in high-risk hematological patients.

Methods

We studied 446 admissions after introduction of an ECIL-4–based protocol (hereafter “ECIL-4 group”) in comparison to a historic cohort of 512 admissions. Primary clinical endpoints were the incidence of infectious complications including septic shock, infection-related intensive care unit (ICU) admission, and overall mortality. Secondary endpoints included the incidence of recurrent fever, bacteremia, and antibiotic consumption.

Results

Bacteremia occurred more frequently in the ECIL-4 group (46.9% [209/446] vs 30.5% [156/512]; P < .001), without an associated increase in septic shock (4.7% [21/446] vs 4.5% [23/512]; P = .878) or infection-related ICU admission (4.9% [22/446] vs 4.1% [21/512]; P = .424). Overall mortality was significantly lower in the ECIL-4 group (0.7% [3/446] vs 2.7% [14/512]; P = .016), resulting mainly from a decrease in infection-related mortality (0.4% [2/446] vs 1.8% [9/512]; P = .058). Antibiotic consumption was significantly reduced by a median of 2 days on antibiotic therapy (12 vs 14; P = .001) and 7 daily antibiotic doses (17 vs 24; P < .001) per admission period.

Conclusions

Our results support implementation of ECIL-4 recommendations to be both safe and effective based on real-world data in a large high-risk patient population. We found no increase in infectious complications and total antibiotic exposure was significantly reduced.

Retrospective Analysis of Bacterial Isolates during Blood Stream Infections in Children with Chemotherapy-induced Febrile Neutropenia: A Single Centre Experience

Introduction The recent advances in cancer treatment have resulted in significant improvement in the outcome of pediatric cancers. However, febrile neutropenia (FN) is the most important cause of mortality and morbidity in pediatric cancer patients and is a crucial limiting factor for the outcome. The greatest threat that we are facing is the emergence of pan drug-resistant (PDR) organisms.

Objectives To study bacterial organisms causing bloodstream infections (BSI) during febrile neutropenia episodes, their antibiotic sensitivity pattern, impact on treatment outcome during the intensive phase of chemotherapy, and the association between prior administration of antibiotics and emergence of multidrug-resistant organisms (MDR).

Materials and Methods This retrospective study was conducted in patients between the age group of 0 to 18 years who were treated for malignancies in the division of pediatric oncology at a tertiary center from August 2017 to December 2020. Blood cultures were collected under aseptic precautions, and they were processed as per the Clinical and Laboratory Standard Institute Guideline (CLSI) 2017.

Results A total of 122/159 (76.7%) patients were diagnosed to have hematological malignancies, and 37/159 (23.3%) patients were found to be suffering from solid tumors. A total of 309 episodes of FN were documented and 386 cultures were sent, out of which 87/386 (22.53%) cultures were positive for bacteria and 2/386 (2.2%) for fungi. Gram-negative isolates were seen in 51/87 (58.62%) cultures and Gram-positive in 36/87 (41.37%) cultures. Burkholderia cepacia and coagulase-negative Staphylococci (CONS) were the commonest found Gram-negative and Gram-positive bacteria, respectively. MDR bacterial strains were seen in 44/87 (50.57%) cultures and PDR strains in 8/87 (9.2%) cultures. Resistance was higher with Klebsiella species and CONS. There were six mortalities during the induction phase of acute leukemia treatment, out of which 4/6 (66.66%) were due to MDR infections, 1/6 (16.6%) due to fungal infection and chemotherapy refractoriness each.

Conclusion Proven bacterial infections were determined in 22.53% of febrile neutropenia episodes. Most BSI in patients with febrile neutropenia were caused by Gram-negative bacteria. Indiscriminate use of higher antibiotics before referral led to the emergence of MDR organisms, thus compromising the outcome. Our study emphasizes the fact that antibiotic stewardship is a crucial task to counter MDR bacteremia-related morbidity and mortality in neutropenic children.

Next-Generation Sequencing to Detect Pathogens in Pediatric Febrile Neutropenia: A Single-Center Retrospective Study of 112 Cases

Background

Febrile neutropenia (FN) is a frequent complication in immunocompromised patients. However, causative microorganisms are detected in only 10% of patients. This study aimed to detect the microorganisms that cause FN using next-generation sequencing (NGS) to identify the genome derived from pathogenic microorganisms in the bloodstream. Here, we implemented a metagenomic approach to comprehensively analyze microorganisms present in clinical samples from patients with FN.

Methods

FN is defined as a neutrophil count <500 cells/µL and fever ≥37.5°C. Plasma/serum samples of 112 pediatric patients with FN and 10 patients with neutropenia without fever (NE) were sequenced by NGS and analyzed by a metagenomic pipeline, PATHDET.

Results

The putative pathogens were detected by NGS in 5 of 10 FN patients with positive blood culture results, 15 of 87 FN patients (17%) with negative blood culture results, and 3 of 8 NE patients. Several bacteria that were common in the oral, skin, and gut flora were commonly detected in blood samples, suggesting translocation of the human microbiota to the bloodstream in the setting of neutropenia. The cluster analysis of the microbiota in blood samples using NGS demonstrated that the representative bacteria of each cluster were mostly consistent with the pathogens in each patient.

Conclusions

NGS technique has great potential for detecting causative pathogens in patients with FN. Cluster analysis, which extracts characteristic microorganisms from a complex microbial population, may be effective to detect pathogens in minute quantities of microbiota, such as those from the bloodstream.

Patterns of Bacterial Isolates and their Resistance to Antibiotics in Patients with Chemotherapy-induced Febrile Neutropenia at a University Hospital

Objectives

Febrile neutropenia is a major complication of cytotoxic chemotherapy and is associated with a high rate of mortality and morbidity if not treated appropriately. Consequently, it is important to know the bacterial spectrum and pattern of its resistance in each hospital to formulate an appropriate empiric antibiotic regimen. We sought to study the bacterial spectrum in patients with chemotherapy-induced neutropenia and report their resistance patterns.

Methods

We conducted a retrospective study on patients admitted with febrile neutropenia between January 2010 and December 2016 in the oncology unit at Sultan Qaboos University Hospital in Oman. Consecutive patients diagnosed with non-hematological malignancies who had febrile neutropenia and positive blood culture were included in this study.

Results

A total of 76 bacterial isolates were documented in 67 episodes in 62 patients. There were 26 male and 36 female patients. The median age was 51 (14–81) years. The most common cancers were breast cancer (17.7%), non-Hodgkin lymphoma (16.1%), and colon cancer (14.5%). Gram-negative and gram-positive organisms accounted for 73.7% and 26.3% of all isolates, respectively. The most common gram-negative organisms were Pseudomonas aeruginosa (26.8%), Escherichia coli (23.2%), Klebsiella species (17.9%), and Acinetobacter baumannii (12.5%). The most common gram-positive organisms were Staphylococcus aureus (30.0%), followed by coagulase-negative Staphylococcus (25.0%). There were 14 multidrug-resistant organisms and eight extended-spectrum beta-lactamases (ESBL). The resistance among gram-negative organisms to the commonly used broad-spectrum antibiotics was 23.5–55.6%. No resistance was recorded against vancomycin amongst the gram-positive organisms. Eight (12.1%) patients died while neutropenic.

Conclusions

Gram-negative organisms were the predominant organisms. There is a high rate of resistance to the commonly used antibiotics. Using a combination of antibiotics is warranted in patients presenting with chemotherapy-induced febrile neutropenia.

The role of serum albumin/globulin ratio in combination with prognostic risk indexes of febrile neutropenia

OBJECTIVES

The aim of this study was to evaluate the effect of the serum albumin/globulin ratio (AGR) on the 30-day mortality of febrile neutropenia (FEN). The second aim of the study was to evaluate the effect of the combination of the AGR with the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) risk indexes on 30-day mortality of FEN.

METHODS

A retrospective study evaluating the effect of serum AGR, MASCC and CISNE scores on 30-day FEN mortality.

RESULTS

A total of 137 FEN episodes in 120 patients were included in this study. Nineteen patients (14%) died within the first 30 days of FEN episodes. The 30-day mortality rate was calculated as 4% in patients with high AGR and 23% in patients with low AGR (P = .002). According to the MASCC and CISNE risk scores, the mortality rates in low-risk patients were 8% and 6%, respectively, and in the high-risk group 22% and 29%, respectively (P = .024 vs P < .001). In the group of patients with MASCC <21 and CISNE ≥3, the 30-day mortality rate was 7%, when the AGR was >1.13, and in those with AGR ≤1.13 mortality rate increased to 50% (P = .012).

CONCLUSION

A low AGR in a patient with FEN was found to be associated with an increased risk of 30-day mortality. Combining the AGR with MASCC and CISNE risk indexes might increase the predictive value of these scoring systems on 30-day mortality.

Open-Label Phase II Prospective, Randomized, Controlled Study of Romyelocel-L Myeloid Progenitor Cells to Reduce Infection During Induction Chemotherapy for Acute Myeloid Leukemia

PURPOSE

Standard cytotoxic induction chemotherapy for acute myeloid leukemia (AML) results in prolonged neutropenia and risk of infection. Romyelocel-L is a universal, allogeneic myeloid progenitor cell product being studied to reduce infection during induction chemotherapy.

PATIENTS AND METHODS

One hundred sixty-three patients with de novo AML (age ≥ 55 years) receiving induction chemotherapy were randomly assigned on day 0 (d0), of whom 120 were evaluable. Subjects received either romyelocel-L infusion on d9 with granulocyte colony-stimulating factor (G-CSF) starting daily d14 (treatment group) or G-CSF daily alone on d14 (control) until absolute neutrophil count recovery to 500/µL. End points included days in febrile episode, microbiologically defined infections, clinically diagnosed infection, and days in hospital.

RESULTS

Mean days in febrile episode was shorter in the treatment arm from d15 through d28 (2.36 v 3.90; P = .02). Similarly, a trend toward decreased microbiologically defined infections and clinically diagnosed infection in the treatment arm was observed from d9 to d28 (35.6% v 47.5%; P = .09), reaching a statistically significant difference from d15 to d28 (6.8% v 27.9%; P = .002). Because of this, antibacterial or antifungal use for treatment of an infection was significantly less in the treatment group (d9-d28: 44.1% v 63.9%; P = .01). Significantly fewer patients in the treatment arm received empiric antifungals from d9 tod28 (42.4% v 63.9%; P = .02) and d15-d28 (42.4% v 62.3%; P = .02). Patients in the treatment arm also had 3.2 fewer hospital days compared with control (25.5 v 28.7; P = .001). Remission rates and days to absolute neutrophil count recovery were similar in the two groups. No patients in the romyelocel-L plus G-CSF group died because of infection compared with two patients in the control arm. No graft-versus-host disease was observed.

CONCLUSION

Subjects receiving romyelocel-L showed a decreased incidence of infections, antimicrobial use, and hospitalization, suggesting that romyelocel-L may provide a new option to reduce infections in patients with AML undergoing induction therapy.

Presence of viremia during febrile neutropenic episodes in patients undergoing chemotherapy for malignant neoplasms

The importance of viral infections as a leading cause of morbidity and mortality is well documented in severely immunosuppressed patients undergoing allogeneic stem cell transplantation. By contrast, viral infections generally receive less attention in patients with malignant disorders undergoing chemotherapy, where the onset of neutropenic fever is mostly associated with bacterial or fungal infections, and screening for viral infections is not routinely performed. To address the occurrence of invasive viral infections in a clinical setting commonly associated with less pronounced immunosuppression, we have prospectively screened 237 febrile neutropenic episodes in pediatric (n = 77) and adult (n = 69) patients undergoing intensive chemotherapy, primarily for treatment of acute leukemia. Serial peripheral blood specimens were tested by RQ-PCR assays for the presence and quantity of the clinically relevant viruses CMV, EBV, HHV6 and HAdV, commonly reactivated in highly immunocompromised patients. Viremia was documented in 36 (15%) episodes investigated, including the detection of HHV6 (n = 14), EBV (n = 15), CMV (n = 6), or HAdV (n = 1). While low or intermediate levels of viremia (<10⁴ virus copies/mL) were commonly associated with bacterial or fungal co-infection, viremia at higher levels (>10⁴ copies/mL) was documented in patients without evidence for other infections, raising the possibility that at least in some instances the onset of fever may have been attributable to the virus detected. The observations suggest that viral infections, potentially resulting from reactivation, might also play a clinically relevant role in patients receiving chemotherapy for treatment of malignant neoplasms, and routine screening for viremia in this clinical setting might be warranted.

Incidence and predictive risk factors of neutropenic sepsis in post-chemotherapy febrile patients in emergency department: A single-center retrospective longitudinal study

Introduction:

Neutropenic sepsis is an emergency sequela in post-chemotherapy fever. Its definition comprises of spectrums of diseases with variable quoted mortality. This study aims to evaluate the incidence of “modified” neutropenic sepsis, with a more stringent definition employed. Predictive risk factors toward occurrence of “modified” neutropenic sepsis among Chinese patients would also be explored.

Methods:

A single-center retrospective longitudinal study was conducted in a medium-sized regional hospital in Hong Kong. All patients with diagnoses of post-chemotherapy fever fulfilling the inclusion and exclusion criteria were recruited. Baseline characteristics and outcome variables of each case subject were collected. Six potential predictive risk factors were chosen for further analysis. Case subjects were followed up for the inpatient progress and outcomes. Relative risks of each risk factor to “modified” neutropenic sepsis were calculated.

Results:

A total of 135 case subjects were recruited. Five developed “modified” neutropenic sepsis, that is, incidence 3.70% (95% confidence interval = 1.59%–8.38%). Only background hematological malignancy was found to be significantly associated with the outcome of “modified” neutropenic sepsis (Relative Risk [RR] 13.2, 95% confidence interval = 1.56–115.70, p = 0.010), with an incidence of 12.9% (95% confidence interval = 5.14%–28.85%). Hematological malignancy was also found to be significantly associated with lower median absolute neutrophil counts (0.95 × 109/L vs 2.3 × 109/L, p = 0.005) and longer median hospital stay (8 days vs 6 days, p < 0.001).

Conclusion:

Incidence of “modified” neutropenic sepsis is low. Hematological malignancy is associated with significantly higher rate of “modified” neutropenic sepsis.

Association of proton pump inhibitor use with the development of febrile neutropenia in lymphoma patients

Background: Proton pump inhibitors (PPIs), although relatively safe drugs for reduction of gastric acid production, continue to raise concerns (i.e. potential infectious complications, electrolyte disturbances). PPIs are frequently administered to hemato-oncological patients receiving chemotherapy. The study main objective is to investigate whether PPI use by hemato-oncological patients receiving chemotherapy raises the risk of febrile neutropenia.Methods: This is a retrospective database study of patients under hemato-oncological follow up between January 2007 and December 2015, treated with different chemotherapy regimens. Comparative analysis assessed frequencies and types of febrile neutropenia among patients with or without PPI treatment. Multivariate analyses were performed adjusting for age, sub-type of malignancy and specific PPI administered.Results: 247 patients were included, 18-91 years of age (mean 61.6 ± 16), 120 (48.58%) female; amongst 66 (26%) how were hospitalized for febrile neutropenia, 50 (75.8%) received PPIs.Multivariate analysis found three risk factors associated with the development of febrile neutropenia in hematological patients: age, diffuse large B-cell lymphoma and treatment with PPIs.Conclusion: A statistically significant association was demonstrated between PPI treatment and the development of febrile neutropenia among hemato-oncological patients. The clinical implications necessitate further caution in administering PPIs to patients with hematological malignancy receiving chemotherapy.

Plasma Microbial Cell-free DNA Next Generation Sequencing in the Diagnosis and Management of Febrile Neutropenia

Background

Standard testing fails to identify a pathogen in most patients with febrile neutropenia (FN). We evaluated the ability of the Karius microbial cell-free DNA sequencing test (KT) to identify infectious etiologies of FN and its impact on antimicrobial management.

Methods

This prospective study (ClinicalTrials.gov; NCT02912117) enrolled and analyzed 55 patients with FN. Up to 5 blood samples were collected per subject within 24 hours of fever onset (T1) and every 2 to 3 days. KT results were compared with blood culture (BC) and standard microbiological testing (SMT) results.

Results

Positive agreement was defined as KT identification of ≥1 isolate also detected by BC. At T1, positive and negative agreement were 90% (9/10) and 31% (14/45), respectively; 61% of KT detections were polymicrobial. Clinical adjudication by 3 independent infectious diseases specialists categorized Karius results as: unlikely to cause FN (N = 0); definite (N = 12): KT identified ≥1 organism also found by SMT within 7 days; probable (N = 19): KT result was compatible with a clinical diagnosis; possible (N = 10): KT result was consistent with infection but not considered a common cause of FN. Definite, probable, and possible cases were deemed true positives. Following adjudication, KT sensitivity and specificity were 85% (41/48) and 100% (14/14), respectively. Calculated time to diagnosis was generally shorter with KT (87%). Adjudicators determined real-time KT results could have allowed early optimization of antimicrobials in 47% of patients, by addition of antibacterials (20%) (mostly against anaerobes [12.7%]), antivirals (14.5%), and/or antifungals (3.6%); and antimicrobial narrowing in 27.3% of cases.

Clinical Trials Registration

NCT02912117

Conclusion

KT shows promise in the diagnosis and treatment optimization of FN.

Anticancer and antimicrobial potential of enterocin 12a from Enterococcus faecium

BACKGROUND

Increase in the number of infections caused by Gram-negative bacteria in neutropenic cancer patients has prompted the search for novel therapeutic agents having dual anticancer and antimicrobial properties. Bacteriocins are cationic proteins of prokaryotic origin that have emerged as one of the most promising alternative antimicrobial agents with applications as food preservatives and therapeutic agents. Apart from their antimicrobial activities, bacteriocins are also being explored for their anticancer potential.

RESULTS

In this study, a broad-spectrum, cell membrane-permeabilizing enterocin with a molecular weight of 65 kDa was purified and characterized from the culture supernatant of vaginal Enterococcus faecium 12a. Enterocin 12a inhibited multidrug-resistant strains of various Gram-negative pathogens such as Salmonella enterica, Shigella flexneri, Vibrio cholerae, Escherichia coli and Gram-positive, Listeria monocytogenes, but had no activities against different strains of gut lactobacilli. The mass spectrometric analysis showed that the enterocin 12a shared partial homology with 4Fe-4S domain-containing redox protein of E. faecalis R712. Further, enterocin 12a selectively inhibited the proliferation of various human cancer cell lines in a dose-dependent manner but not that of normal human peripheral blood mononuclear cells. Enterocin 12a-treated cancer cells showed apoptosis-like morphological changes.

CONCLUSION

Enterocin 12a is a novel bacteriocin that has anticancer properties against human cell lines and negligible activity towards non-malignant cells. Therefore, it should be further evaluated for its anticancer potential in animal models.

[Clinical and microbiological characteristics of bloodstream infections in adult neutropenic patients]

Bloodstream infections (BI) are relevant in neutropenic patients because they are associated with an increased number of complications and death. The objective was determinate the epidemiologic and microbiologic features of the BI in neutropenic patients with solid neoplasm (SN) and hematologic neoplasm (HN). Retrospective study in two third level hospitals between 2009 and 2016. They were included all the patients older than 18 years-old with active oncologic disease and neutropenia, who had BI. Patients with dermatologic cancer other than melanoma where excluded. A total of 143 BI in neutropenic were observed, of which 80.4% occurred in HN. Around 97.9% of the patients had a high-risk neutropenia without differences between both groups. The most frequent site of BI was primary bacteremia (46.9%) and catheter-associated infection (21%), without significant differences between the two groups. The gram negatives bacilli (GNB) predominated over the gram positive cocci (GPC) and they represented 74.1% of the isolated bacteria, being Escherichia coli the most frequent (32.8%). Among the gram positive cocci, Staphylococcus aureus (28.1%) was the most frequent isolated, followed by coagulase-negative Staphylococci (CNS). There were no differences in microbiological isolates between both groups. With regard to the antimicrobial susceptibility 67.5% of the CNS, 17.6% of the E. coli and 27.6% of the Klebsiella pneumoniae were multiresistant with no differences between both groups. Only 11.1% of S. aureus isolates were methicillin resistant. In conclusion BI of the neutropenic patients where most frequents within patients with HN, GNB were the main microbiological isolates. High mortality was observed in neutropenic patients with BI.

Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia

OBJECTIVES

Febrile neutropenia (FN) is severe and potentially life-threatening in oncologic patients. The objective of this study is to define the factors associated with severe adverse outcomes of pediatric FN.

METHODS

A retrospective and prospective descriptive study performed in pediatric patients diagnosed with FN at King Chulalongkorn Memorial Hospital from January 2013 to December 2017. Severe adverse events defined as the presence in one of these following oxygen therapies, mechanical ventilator, shock, admission to ICU, renal dysfunction, and liver dysfunction.

RESULTS

The study included 267 patients with 563 febrile neutropenia episodes. The median (range) age was 5.1 years (1 month-15 year). Among 563 febrile neutropenia episodes, 115 episodes (20%) developed severe adverse events. The FN patients were classified into low and high-risk groups, 91% of patients with severe adverse events and all 21 patients who died were in high risk group. The overall mortality rate was 3.1%. Factors associated with severe adverse events were fungal infection (aOR 6.51, 95%CI 2.29-18.56), central venous catheter insertion (aOR 4.28, 95% CI 2.51-7.29), CPG defined high risk (aOR 3.35, 95%CI 1.56-7.17), viral infection (aOR 2.72, 95%CI 1.05-7.06), lower respiratory tract infection (aOR 2.52, 95%CI 1.09-5.82) and treatment not according to CPG (aOR 2.47, 95% CI 1.51-4.03).

CONCLUSIONS

Fungal and viral infection, central venous catheter insertion, lower respiratory tract infection, CPG defined high risk and treatment not according to CPG were associated factors of increased risk for severe adverse events. Our current institutional CPG for FN in children was applicable and improved clinical outcomes for this group of patients. <br />.

Treatment-Related Mortality From Infectious Complications in an Acute Leukemia Clinic

Background

The main causes of mortality in patients with acute leukemia are the infectious complications. The author wanted to know the induction-related mortality and treatment-related mortality in the acute leukemia patients at the Instituto Nacional de Cancerologia (INCan), Mexico. Also the author is interested in finding out the micro-organism and the main site of infection to make some changes in the management of patients in these clinics. Primary objective was induction chemotherapy-related mortality and treatment-related mortality. Secondary objective was to determine the site of infection, micro-organism, type of chemotherapy related with more mortality and relapse mortality.

Methods

This was a retrospective case-series analysis of all patients who were admitted to the INCan Acute Leukemia Clinic between January 2012 and December 2015 with febrile neutropenic complications. We reviewed the case histories of all patients, including those with acute lymphoblastic leukemia (ALL), acute myeloblastic leukemia (AML), acute biphenotypic leukemia and acute promyelocytic leukemia, regardless of disease status (newly diagnosed or relapsed) at the time of clinic attendance. Patients who died as the result of an infectious complication during the analysis window were identified, and their demographics, disease characteristics, treatment history (chemotherapy within 45 days of date of death) and details of the infectious complication resulting in death were collected.

Results

Of the 313 patients studied during that time period, 84 (27%) died as a result of infectious complications. Lung infections were the most common, accounting for 67% of all deaths from infectious complications. Escherichia coli producing extended-spectrum beta-lactamases was the most frequently isolated infectious organism (12 patients; 14%). The majority of deaths occurred during either induction therapy (27 patients; 32%) or treatment for a first relapse (25 patients; 30%). Hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone (hyper-CVAD) was the chemotherapy regimen most commonly received within 45 days prior to death (17 patients; 20%).

Conclusions

Our findings suggest a need for long-term management and supportive care to prevent infectious complication-associated fatalities during both initial chemotherapy and subsequent disease relapse in patients with acute leukemia. The use of prophylaxis will help patients to prevent complications.

Gut microbiota profiles of treatment-naïve adult acute myeloid leukemia patients with neutropenic fever during intensive chemotherapy

The intestinal bacterial flora of febrile neutropenic patients has been found to be significantly diverse. However, there are few reports of alterations of in adult acute myeloid leukemia (AML) patients. Stool samples of each treatment-naïve AML patient were collected the day before initiation of induction chemotherapy (pretreatment), on the first date of neutropenic fever and first date of bone marrow recovery. Bacterial DNA was extracted from stool samples and bacterial 16s ribosomal RNA genes were sequenced by next-generation sequencing. Relative abundance, overall richness, Shannon's diversity index and Simpson's diversity index were calculated. No antimicrobial prophylaxis was in placed in all participants. Ten cases of AML patients (4 male and 6 female) were included with a median age of 39 years (range: 19–49) and all of patients developed febrile neutropenia. Firmicutes dominated during the period of neutropenic fever, subsequently declining after bone marrow recovery a pattern in contrast to that shown by Bacteroidetes and Proteobacteria. Enterococcus was more abundant in the febrile neutropenia period compared to pretreatment (mean difference +20.2; p < 0.0001) while Escherichia notably declined during the same period (mean difference -11.2; p = 0.0064). At the operational taxonomic unit (OTU) level, there was a significantly higher level of overall richness in the pretreatment period than in the febrile neutropenic episode (mean OTU of 203.1 vs. 131.7; p = 0.012). Both of the diversity indexes of Shannon and Simpson showed a significant decrease during the febrile neutropenic period. Adult AML patients with a first episode of febrile neutropenia after initial intensive chemotherapy demonstrated a significant decrease in gut microbiota diversity and the level of diversity remained constant despite recovery of bone marrow.

Microbiological Profile of Blood Stream Infections in Febrile Neutropenic Patients at a Tertiary Care Teaching Hospital in Rishikesh, Uttarakhand

Context  Febrile neutropenia is a serious complication of chemotherapy affecting patients with both hematological and solid malignancies, respectively. To the best of our knowledge, there is paucity of literature from Uttarakhand, India on microbiological profile of blood stream infections (BSIs) in febrile neutropenic patients. Aims  The study aims to generate preliminary data on microbiological profile and antibiotic resistance pattern of BSIs in febrile neutropenic patients. Settings and Design   The design involved cross-sectional study from January 1, 2019 to July 31, 2019. Methods and Materials  Data of nonrepetitive paired peripheral blood samples obtained from 306 consecutive febrile neutropenic cancer patients of all age groups and both sexes, for culture and sensitivity testing, were retrospectively analyzed. All blood samples were subjected to aerobic culture using BACT/ALERT three-dimensional microbial detection system. Growth obtained in culture was identified by conventional biochemical methods. Antibiotic susceptibility testing of bacterial isolates was performed using modified Kirby Bauer disk diffusion method. Statistical Analysis Used   Fisher's exact test was used for the analysis. Results  Mean age ± SD of the study population was 32.39 ± 10.56 years with a male to female ratio of 1.55:1. 74.18% of the blood samples were received from patients suffering from hematological malignancies. Microbiologically confirmed BSIs were observed in 27.1% patients. Gram-negative bacilli were predominantly isolated in culture with Klebsiella spp . being the most common. Percentage resistance values of gram-negative bacilli to aminoglycosides, β-lactam/β-lactamase inhibitor combinations, fluoroquinolones, cephalosporins, carbapenems, chloramphenicol, ampicillin, co-trimoxazole, and doxycycline were 26.6 to 91.7%, 8.3 to 86.6%, 10 to 66.7%, 13.3 to 73.3%, 8.3 to 73.3%, 80 to 93.3%, 13.3 to 20%, 16.7 to 66.6%, and 13.3 to 16.7%, respectively. Conclusion  Implementation of antimicrobial stewardship program along with hospital infection control practices is needed for preventing BSIs due to MDR organisms.

Carboplatin-induced myelosuppression as related to body weight in dogs

Smaller dogs are known to have an increased risk of chemotherapy-induced myelosuppression for doxorubicin, mitoxantrone and melphalan. This retrospective study aimed to determine if dogs <15 kg and <10 kg experienced greater degrees of myelosuppression following treatment with carboplatin chemotherapy compared with dogs ≥15 kg. One hundred and one dogs treated with carboplatin for a variety of malignancies were retrospectively analysed. Eight dogs (61%) weighing <10 kg, three (38%) weighing 10 kg to <15 kg and 14 (17%) weighing ≥15 kg experienced a grade 3 or 4 neutropenia. Five dogs (38%) weighing <10 kg, two (25%) weighing 10 kg to <15 kg and 13 (16%) weighing ≥15 kg experienced a grade 3 or 4 thrombocytopenia. Dogs <10 kg were significantly more likely to develop a grade 3 or 4 neutropenia following carboplatin than dogs ≥10 kg (3.5 RR; 95% CI, 1.9-6.3; P < .001). Dogs <15 kg were also significantly more likely to develop a grade 3 or 4 neutropenia than dogs ≥15 kg (3 RR; 95% CI, 1.6-5.6; P = .004). Dogs <10 kg were significantly more likely to develop a grade 3 or 4 thrombocytopenia than those dogs ≥10 kg (2.5 RR; 95% CI, 1.1-5.6; P = .006). Hospitalization was significantly more likely for dogs <10 kg vs ≥10 kg (P = .014) as well as for dogs <15 kg vs ≥15 kg (P = .039). This study demonstrates an increased risk of carboplatin-induced myelosuppression in dogs <15 kg, and particularly those <10 kg. This information should be considered by clinicians when making decisions regarding the initial carboplatin dose for smaller canine patients, especially those <15 kg.

Microbiota-based approaches to mitigate infectious complications of intensive chemotherapy in patients with acute leukemia

Despite advances in antimicrobial treatments, infection remains a common complication of intensive chemotherapy in patients with acute leukemia. It has become progressively apparent that the current antimicrobial focus has shortcomings that result from disruption of the commensal microbial communities of the gut. These effects, collectively known as dysbiosis, have been increasingly associated worldwide with growing complications such as Clostridioides difficile infection, systemic infections, and antibiotic resistance. A revision of the current practice is overdue. Several innovative concepts have been proposed and tested in animal models and humans, with the overarching goal of preventing damage to the microbiota and facilitating its recovery. In this review, we discuss these approaches, examine critical knowledge gaps, and explore how they may be filled in future research.

Symptom Clusters in Postchemotherapy Neutropenic Fever in Hematological Malignancy: Associations Among Sickness Behavior Symptom Cluster, Inflammatory Biomarkers of Procalcitonin and C-Reactive Protein, and Febrile Measures

CONTEXT

Little research has been conducted to investigate symptom clusters in postchemotherapy neutropenic fever (NF), their relationships with inflammatory biomarkers, and febrile outcome measures in patients with hematological malignancy, a population with high febrile rates incurring considerable costs to the health care system.

OBJECTIVES

The aim of the present study was to investigate these.

METHODS

One hundred four NF episodes were observed in patients with hematological malignancy who were enrolled in the study. Patient-reported symptoms were recorded using the M.D. Anderson Symptom Inventory. Inflammatory biomarkers of procalcitonin (PCT) and C-reactive protein (CRP), vital signs, blood specimens for cultures, blood cell counts, and biochemistry were also collected. Serious complications from NF were reviewed from medical records if documented. Exploratory factor analysis and Spearman's rank correlation were used in the data analysis.

RESULTS

Three symptom clusters-sickness behavior, chemotherapy neurotoxicity, and emesis-were identified by exploratory factor analysis. The factor score of the sickness behavior cluster was significantly correlated with CRP (P < 0.05), PCT (P < 0.01), and the highest (P < 0.05) and maximum increased in (P < 001) temperatures at the onset (first day) of neutropenic fever.

CONCLUSION

This study identified symptom clusters of sickness behavior, chemotherapy neurotoxicity, and emesis and highlighted significant associations between sickness behavior cluster, PCT, CRP, and febrile temperatures at the onset of postchemotherapy NF. These areas have lacked exploration in previous research. Monitoring and analyzing patient-reported sickness behavior symptoms, PCT, CRP, and temperature data would provide significant complementary data for the management and surveillance of postchemotherapy NF in hematological malignancy.

Impact of cardiovascular comorbidities on inpatient mortality in patients hospitalized with neutropenic fever

INTRODUCTION

Concomitant cardiovascular comorbidities in patients with cancer are not uncommon. There is limited data on the impact of cardiovascular comorbidities on in-hospital mortality in patients admitted with neutropenic fever.

METHODS

This is a retrospective cohort study using the 2016 NIS database of adults (> 18 years old) hospitalized for neutropenic fever as the primary diagnosis. The primary outcome studied is all-cause mortality in patients with neutropenic fever. ICD-10-CM codes were used to identify cardiovascular risk factors including smoking; hyperlipidemia; peripheral vascular diseases; hypertension; history of cerebrovascular disease or transient ischemic attack; and cardiovascular morbidities including atrial fibrillation, coronary artery disease, and congestive heart failure. Multivariate linear regression analysis was used to adjust for cofounders.

RESULTS

A total of 28,060 patients were admitted with neutropenic fever in 2016. Average age was 43.9 ± 1.7 years, and 49.3% were females. Among the cases identified, 205 patients died during hospitalization with an overall in-hospital mortality of 0.7%. Atrial fibrillation was independently associated with higher in-hospital mortality (odds ratio [OR] 3.01; CI 1.38 to 6.57; p = 0.005) as was congestive heart failure (OR 3.15; CI 1.08 to 10.14; p = 0.049).

CONCLUSION

Atrial fibrillation and congestive heart failure were associated with higher inpatient mortality in patients with neutropenic fever. Identifying the risk factors for increased mortality in patients with neutropenic fever is important for risk stratification and guiding clinicians in taking therapeutic decisions in this set of patients.

Linezolid is safe on platelet count for AML patients during myelosuppression after consolidation chemotherapy

BACKGROUND

Patients with acute myeloid leukaemia (AML) often develop severe infections during myelosuppression after chemotherapy. Linezolid is an appropriate choice for these patients when coverage of positive bacteria is needed. An important side effect of linezolid is linezolid-induced thrombocytopenia; so, the safety of linezolid for AML patients in myelosuppression is of concern. No study has focused on platelets in these patients.

METHODS

We reviewed 1356 AML patients who received consolidation chemotherapy in our hospital during January 2009 and June 2019. Among them, 36 patients were treated with linezolid and 41 with vancomycin. We counted the days of platelet count <20*10E9/L, <50*10E9/L, the lowest platelet count, total quantity of platelet transfusion and clinical bleeding events of these patients, to evaluate the safety of linezolid during myelosuppression in AML patients.

RESULTS

The days of platelet count <20*10E9/L in the linezolid group and vancomycin group were 6.2 ± 2.5 days and 6.7 ± 2.9 days, and the days of platelet count <50*10E9/L in the linezolid group and vancomycin group were 10.9 ± 3.6 days and 11.7 ± 4.0 days, respectively; there was no significant difference between the two groups. No life-threatening severe bleeding events occurred in either group.

CONCLUSION

This retrospective clinical study suggests that it is safe to manage AML patients in complete remission during myelosuppression after standard consolidation chemotherapy with idarubicin and cytarabine, with about 7 days of linezolid therapy.

The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model

PURPOSE

Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments.

METHODS

A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness.

RESULTS

The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options.

DISCUSSION

Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.

Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients

Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key “safety net” in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible “safety net” for these immunocompromised hosts.

Comportamiento de un modelo de predicción de infección bacteriana invasiva en niños con cáncer, neutropenia y fiebre

Objetivo: Describir el comportamiento de un modelo de predicción de infección bacteriana invasiva en niños con cáncer que cursan con neutropenia y fiebre,atendidos en el Hospital Infantil San Vicente Fundación (HISVF), en el año 2017. Materiales y métodos: Estudio descriptivo, de corte transversal y de período,que incluyó pacientes menores de 14 años con diagnóstico de algún tipo de cáncer que ingresaron al HISVF entre enero y diciembre de 2017, con diagnóstico de neutropenia y cuadro febril. Resultados: Se encontraron 99 episodios en 44 pacientes con NF. Al analizar la muestra según el grupo de riesgo estratificado y el desenlace aislamiento microbiológico o muerte, se encontraron diferencias entre los dos grupos. Estas diferencias muestran una mayor mortalidad y frecuencia de infección bacteriana invasiva en los pacientes clasificados como de alto riesgo.Discusión: La aplicación de estos criterios puede ser usada para un mejor direccionamiento del enfoque terapéutico incluyendo: el uso racional de antibióticos y un alta temprana o un seguimiento ambulatorio.

Multidisciplinary Tool Kit for Febrile Neutropenia: Stewardship Guidelines, Staphylococcus aureus Epidemiology, and Antibiotic Use Ratios

PURPOSE

Inappropriate vancomycin for febrile neutropenia (FN) is an ideal antimicrobial stewardship target. To improve vancomycin prescribing, we instituted a multifaceted intervention, including an educational guideline with audit for compliance; an antibiotic use audit; and an assessment of local burden of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection.

MATERIALS AND METHODS

We conducted a quasi-experimental pre-post intervention review of vancomycin initiation for FN on a 32-bed hematology/oncology unit. A retrospective chart review was conducted from November 2015 to May 2016 (preintervention period). In January 2017, we implemented an institutional FN guideline emphasizing criteria for appropriate use. Vancomycin audit was conducted from February 2017 to October 2017 (postintervention period). The primary outcome was appropriateness of vancomycin initiation. We then compared average antibiotic use (days of therapy per 1,000 patient days) for vancomycin and cefepime before and after intervention. Finally, unit-wide MRSA screening cultures were obtained upon admission and bimonthly for 6 weeks (October 2, 2017, to November 9, 2017). Screened patients were followed for 12 months for clinical MRSA infection.

RESULTS

Forty-three (49%) of 88 preintervention patients were started on empiric vancomycin appropriately, compared with 59 (66%) of 90 postintervention patients (P = .02). There was a significant decrease in vancomycin use after intervention. Six (7.1%) of 85 patients screened positive for MRSA colonization. During the 12-month follow-up, no colonized patients developed clinical MRSA infections (positive predictive value, 0.0%). Of the 79 noncolonized patients, 2 developed a clinically significant infection (negative predictive value, 97.5%).

CONCLUSION

Guideline-focused education can improve vancomycin appropriateness in FN and should be bundled with education and feedback about local MRSA epidemiology and antibiotic use rates for maximal stewardship impact.

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

INTRODUCTION

Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department.

METHODS

A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality.

RESULTS

Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died.

CONCLUSION

Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.