Emergency Department Management of Patients With Febrile Neutropenia: Guideline Concordant or Overly Aggressive?

The gut microbiome: an important factor influencing therapy for pediatric acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most prevalent form of pediatric leukemia. The gut microbiome (GM) is crucial for proper nutrition, immunity, and biological conflict. Since the relationship between ALL and GM is bidirectional, ALL occurrence and treatment are closely related to GM destruction and the development of impaired immunity. Studies have discovered significant GM alterations in patients with ALL, including decreased diversity, that are likely directly caused by the development of ALL. Chemotherapy, antibiotic therapy, and hematopoietic stem cell transplantation (HSCT) are the mainstays of treatment for pediatric ALL. These approaches affect the composition, diversity, and abundance of intestinal microorganisms, which in turn affects therapeutic efficiency and can cause a variety of complications. Modulating the GM can aid the recovery of patients with ALL. This article discusses the various treatment modalities for pediatric ALL and their corresponding effects on the GM, as well as the changes in the GM that occur in children with ALL from diagnosis to treatment. Gaining a greater understanding of the link between ALL and the GM is expected to help improve treatment for pediatric ALL in the future.

Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis: the EASI-SWITCH RCT

Background

Neutropenic sepsis is a common complication of systemic anticancer treatment. There is variation in practice in timing of switch to oral antibiotics after commencement of empirical intravenous antibiotic therapy.

Objectives

To establish the clinical and cost effectiveness of early switch to oral antibiotics in patients with neutropenic sepsis at low risk of infective complications.

Design

A randomised, multicentre, open-label, allocation concealed, non-inferiority trial to establish the clinical and cost effectiveness of early oral switch in comparison to standard care.

Setting

Nineteen UK oncology centres.

Participants

Patients aged 16 years and over receiving systemic anticancer therapy with fever (≥ 38°C), or symptoms and signs of sepsis, and neutropenia (≤ 1.0 × 109/l) within 24 hours of randomisation, with a Multinational Association for Supportive Care in Cancer score of ≥ 21 and receiving intravenous piperacillin/tazobactam or meropenem for < 24 hours were eligible. Patients with acute leukaemia or stem cell transplant were excluded.

Intervention

Early switch to oral ciprofloxacin (750 mg twice daily) and co-amoxiclav (625 mg three times daily) within 12-24 hours of starting intravenous antibiotics to complete 5 days treatment in total. Control was standard care, that is, continuation of intravenous antibiotics for at least 48 hours with ongoing treatment at physician discretion.

Main outcome measures

Treatment failure, a composite measure assessed at day 14 based on the following criteria: fever persistence or recurrence within 72 hours of starting intravenous antibiotics; escalation from protocolised antibiotics; critical care support or death.

Results

The study was closed early due to under-recruitment with 129 patients recruited; hence, a definitive conclusion regarding non-inferiority cannot be made. Sixty-five patients were randomised to the early switch arm and 64 to the standard care arm with subsequent intention-to-treat and per-protocol analyses including 125 (intervention n = 61 and control n = 64) and 113 (intervention n = 53 and control n = 60) patients, respectively. In the intention-to-treat population the treatment failure rates were 14.1% in the control group and 24.6% in the intervention group, difference = 10.5% (95% confidence interval 0.11 to 0.22). In the per-protocol population the treatment failure rates were 13.3% and 17.7% in control and intervention groups, respectively; difference = 3.7% (95% confidence interval 0.04 to 0.148). Treatment failure predominantly consisted of persistence or recurrence of fever and/or physician-directed escalation from protocolised antibiotics with no critical care admissions or deaths. The median length of stay was shorter in the intervention group and adverse events reported were similar in both groups. Patients, particularly those with care-giving responsibilities, expressed a preference for early switch. However, differences in health-related quality of life and health resource use were small and not statistically significant.

Conclusions

Non-inferiority for early oral switch could not be proven due to trial under-recruitment. The findings suggest this may be an acceptable treatment strategy for some patients who can adhere to such a treatment regimen and would prefer a potentially reduced duration of hospitalisation while accepting increased risk of treatment failure resulting in re-admission. Further research should explore tools for patient stratification for low-risk de-escalation or ambulatory pathways including use of biomarkers and/or point-of-care rapid microbiological testing as an adjunct to clinical decision-making tools. This could include application to shorter-duration antimicrobial therapy in line with other antimicrobial stewardship studies.

Trial registration

This trial is registered as ISRCTN84288963.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/140/05) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

Impact of Adding a Rapid PCR-Based Blood Culture Identification Panel to the Antimicrobial Stewardship Program of Patients with Febrile Neutropenia in a Peruvian Referral Hospital

The addition of Biofire^® FilmArray^® Blood Culture Identification panel 2 (BCID2) to the antimicrobial stewardship program (ASP) could improve outcomes in bloodstream infections (BSI) of patients with febrile neutropenia (FN). A pre- and post-quasi-experimental single-center study was conducted at a reference hospital in Peru. Three groups were considered: patients with BSI before ASP intervention (control group), patients with BSI after ASP intervention (group 1), and patients with BSI after ASP intervention plus BCID2 PCR Panel implementation (group 2). Overall, 93 patients were identified (32 control, 30 group 1, 31 group 2). The median time to effective therapy was significantly shorter in group 2 compared to group 1 and control group, respectively (3.75 vs. 10 h, p = 0.004; 3.75 vs. 19 h, p < 0.001). No significant differences in terms of relapse of bacteremia, in-hospital mortality (all cause), and 30-day-all-cause hospital readmission between the three study periods were found. The appropriateness of empirical antimicrobial use, adding or change, and the following de-escalation or discontinuation was significant when the two intervention periods were compared with the control group (p < 0.001). In addition to the lack of local studies documenting the microbiological profile of FN episodes, adding syndromic panels-based testing could allow for the consolidation of ASP strategies.

Clinical factors predicting return emergency department visits in chemotherapy-induced febrile neutropenia patients

BACKGROUND

Although chemotherapy-induced febrile neutropenia (FN) is the most common and life-threatening oncologic emergency, the characteristics and outcomes associated with return visits to the emergency department (ED) in these patients are uncertain. Hence, we aimed to investigate the predictive factors and clinical outcomes of chemotherapy-induced FN patients returning to the ED.

METHOD

This single-center, retrospective observational study spanning 14 years included chemotherapy-induced FN patients who visited the ED and were discharged. The primary outcome was a return visit to the ED within five days. We conducted logistic regression analyses to evaluate the factors influencing ED return visit.

RESULTS

This study included 1318 FN patients, 154 (12.1%) of whom revisited the ED within five days. Patients (53.3%) revisited the ED owing to persistent fever (56.5%), with no intensive care unit admission and only one mortality case who was discharged hopelessly. Multivariable analysis revealed that shock index >0.9 (odds ratio [OR]: 1.45, 95% confidence interval [CI], 1.01-2.10), thrombocytopenia (<100 × 10³/uL) (OR: 1.64, 95% CI, 1.11-2.42), and lactic acid level > 2 mmol/L (OR: 1.51, 95% CI, 0.99-2.25) were associated with an increased risk of a return visit to the ED, whereas being transferred into the ED from other hospitals (OR: 0.08; 95% CI, 0.005-0.38) was associated with a decreased risk of a return visit to the ED.

CONCLUSION

High shock index, lactic acid, thrombocytopenia, and ED arrival type can predict return visits to the ED in chemotherapy-induced FN patients.

Going local: Evaluating guideline adherence and appropriateness of antibiotic prescribing in patients with febrile neutropenia at an academic teaching hospital

Background

Febrile neutropenia (FN) is a medical emergency with significant morbidity and mortality for oncology patients, requiring comprehensive workup and timely antibiotic administration. We evaluated concordance with locally developed FN guidelines and outcomes of cancer patients admitted to general internal medicine at an academic teaching hospital.

Methods

We conducted a retrospective observational cohort study of patients admitted between July 1, 2016, and June 30, 2017, for FN. Patients were classified as having low-risk or high-risk FN according to their malignancy and chemotherapy. Primary outcome was the proportion of patients receiving guideline-concordant antibiotics within 48 hours of admission to general internal medicine. Secondary outcomes were the proportion of patients in whom empirical antibiotics were active against pathogens isolated, rate of antibiotic-associated adverse events, and in-hospital mortality. We used logistic regression to model relationship between FN risk and guideline-concordant antibiotics.

Results

Among 100 patients included, 34 (34%) were low-risk FN and 66 (66%) were high-risk. Proportion of guideline-concordant empirical antibiotics was significantly lower among low-risk FN patients than high-risk patients: 12 (35%) of 34 versus 47 (71%) of 66 (P = .001). Empirical antibiotics were active against 17 (94%) of 18 isolated pathogens. The mortality rate was 3%, and 16% of patients experienced antibiotic-associated adverse events. Hematological malignancy and infectious diseases-trained physician involvement were associated with guideline-concordant prescribing, with adjusted odds ratios of 3.76 (95% CI, 1.46-9.70; P = .006) and 3.71 (95% CI, 1.49-9.23; P = .005), respectively.

Conclusions

Guideline concordance was low compared to published reports. Factors influencing appropriate antimicrobial prescribing in patients with FN warrant further exploration.

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BACKGROUND

Chemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED.

METHODS

A PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: "febrile neutropenia" OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review.

RESULTS

The search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%).

CONCLUSIONS

FN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.

A national study of antibiotic use in Greek pediatric hematology oncology and bone marrow transplant units

OBJECTIVE

We surveyed antimicrobials used in Greek pediatric hematology-oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients.

DESIGN

Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017.

INTERVENTION

In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated.

SETTING

Five of the 6 PHO units in Greece and the single pediatric BMT unit participated.

PARTICIPANTS

Admitted children in each unit who received the first 15 new antibiotic courses each month.

RESULTS

Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children's hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008).

CONCLUSIONS

We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.

Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN

PURPOSE

Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED.

METHODS

We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay.

RESULTS

Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index.

CONCLUSION

In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.

Characteristics in gut microbiome is associated with chemotherapy-induced pneumonia in pediatric acute lymphoblastic leukemia

Background

Children with acute lymphoblastic leukemia (ALL) undergoing chemotherapy experience a relatively high risk of infection. And the disturbance of gut microbiota is generally believed to impair intestinal barrier function and may induce bacterial infections and inflammation. The study aimed to investigate the alterations in the gut microbiota and assess its relationship with chemotherapy-induced pneumonia in pediatric ALL patients.

Methods

We conducted a case–control study with 14 cases affected by pneumonia and 44 unaffected subjects and characterized the physiological parameters and gut microbiota by microarray-based technique.

Results

There were significant differences in α- and β-diversity in the affected group compared with the control group. At species level, the LEfSe analysis revealed that Enterococcus malodoratus, Ochrobactrum anthropi and Actinomyces cardiffensis were significantly abundant in the affected subjects. A receiver operating characteristic (ROC) curve yielded the area under the curve (AUC) of 0.773 for classification between the two groups. In addition, the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways involved in the bacterial secretion system were more enriched in the affected group than in the control group.

Conclusions

Gut microbiota alteration was associated with chemotherapy-induced pneumonia in pediatric ALL patients, which provided a new perspective on the personalized clinical care of pediatric ALL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08917-y.

A questionnaire survey on evaluation for penetration and compliance of the Japanese Guideline on Febrile Neutropenia among hematology-oncology physicians and surgeons

PURPOSE

The Japanese Society of Medical Oncology published a guideline (GL) on febrile neutropenia (FN) in 2017. The study's purpose is to reveal how widely GL penetrated among physicians and surgeons providing chemotherapy.

METHODS

A questionnaire survey was conducted with SurveyMonkey™ for members of the Japanese Association of Supportive Care in Cancer and relevant academic organizations. Each question had four options (always do, do in more than half of patients, do in less than half, do not at all) and a free description form. Responses were analyzed with statistical text-analytics.

RESULT

A total of 800 responses were retrieved. Major respondents were experts with more than 10-year experience, physicians 54%, and surgeons 46%. Eighty-seven percent of respondents knew and used GL. Forty-eight percent assessed FN with Multinational Association of Supportive Care in Cancer (MASCC) score "always" or "more than half." Eighty-one percent chose beta-lactam monotherapy as primary treatment in high-risk patients. Seventy-seven percent did oral antibacterial therapy in low-risk patients ambulatorily. Seventy-eight percent administered primary prophylactic G-CSF (ppG-CSF) in FN frequency ≥ 20% regimen. Fifty-nine percent did ppG-CSF for high-risk patients in FN frequency 10-20% regimen. Ninety-seven percent did not use ppG-CSF in FN frequency < 10% regimen. The medians of complete and complete plus partial compliance rates were 46.4% (range 7.0-92.8) and 77.8% (range 35.4-98.7). The complete compliance rates were less than 30% in seven recommendations, including the MASCC score assessment.

CONCLUSION

GL is estimated to be widely utilized, but some recommendations were not followed, presumably due to a mismatch with actual clinical practices in Japan.

Emergency department management of chemotherapy related febrile neutropenia: An opportunity to improve care

BACKGROUND

Febrile neutropenia (FN) is an important oncological emergency seen in the emergency department (ED), and the American Society of Clinical Oncology recommends risk stratification of patients with febrile neutropenia using the Multinational Association for Supportive Care in Cancer (MASCC) Index, with ED discharge on oral antibiotics recommended for low-risk patients.

OBJECTIVES

To determine the prevalence of FN neutropenia and medical system wide ED treatment guideline adherence.

METHODS

We performed a retrospective chart review of all patients with an ICD-10 confirmed diagnosis of FN from January 2016-2019at 13 affiliated EDs within one medical system. Only cancer/chemotherapy related FN were included. Following the MASCC guidelines, we used post-hoc calculations to classify patients as low/high-risk, and compared key clinical variables (mortality, blood culture positivity, interventions).

RESULTS

203 patients were found to have FN. 97.9% (184/203) received broad spectrum antibiotics, including 92% of the low-risk group (60/65). All patients were admitted, and no observed in-hospital mortality was noted in the low-risk group, meanwhile 5.1% (7/138) of the high-risk group died. 14/203 patients had positive blood cultures, none in the low-risk group.

CONCLUSION

The prevalence of FN is low among 13 EDs that had almost 1.7 million ED visits over a 3-year period. Guideline compliance for low-risk FN was poor. All patients were admitted, and nearly all patients received IV fluids and IV antibiotics. Improving FN management to align with national guidelines represents an opportunity to improved ED care of patients with cancer by reducing unnecessary hospitalizations.

Health care experiences for older adults diagnosed with leukemia and lymphoma: Factors associated with emergency department use, timeliness and access of health care

OBJECTIVES

This study examined the association of ED use in the first year of diagnosis and patient experiences in care among older adults with hematologic malignancies.

MATERIALS AND METHODS

Cross-sectional design using SEER-CAHPS® data from 2002 to 2015 to study Medicare fee-for-service enrollees with a primary diagnosis of leukemia or lymphoma. We linked the CAHPS survey data (patient-reported experiences with health services) to patients' cancer registry information and Medicare outpatient claims from the SEER-CAHPS resource. We estimated associations of ED use and clinical characteristics with two CAHPS outcomes - "getting care quickly" (timeliness) and "getting needed care" (access) - with bivariate and multivariate analyses.

RESULTS

The analytic sample included 751 patients, 125 of whom had an ED claim in the first year of cancer diagnosis. The most frequent ED diagnosis clusters were fever and infection (n = 17, 13.6%), orthopedic and injury (16, 12.8%) and pain (16, 12.8%). Significantly more enrollees with an ED claim were diagnosed with lymphoma (p < 0.01), lived in rural areas (p < 0.01), and lived in areas with many families living in poverty (p < 0.01). In adjusted models, enrollees with an ED claim reported significantly worse access to care (β - 4.83; 95%CI -9.29,-0.38; p = 0.03).

CONCLUSION

The management of urgent care concerns for adults with hematologic malignancies remains an important clinical and quality improvement imperative. Further study is warranted to enhance the management of emergent complications in older adults receiving care for hematologic malignancies, with efforts that enhance coordination of ambulatory oncology care.

Current management of chemotherapy-induced neutropenia in adults: key points and new challenges: Committee of Neoplastic Supportive-Care (CONS), China Anti-Cancer Association Committee of Clinical Chemotherapy, China Anti-Cancer Association

Chemotherapy-induced neutropenia (CIN) is a potentially fatal and common complication in myelosuppressive chemotherapy. The timing and grade of CIN may play prognostic and predictive roles in cancer therapy. CIN is associated with older age, poor functional and nutritional status, the presence of significant comorbidities, the type of cancer, previous chemotherapy cycles, the stage of the disease, specific chemotherapy regimens, and combined therapies. There are many key points and new challenges in the management of CIN in adults including: (1) Genetic risk factors to evaluate the patient's risk for CIN remain unclear. However, these risk factors urgently need to be identified. (2) Febrile neutropenia (FN) remains one of the most common reasons for oncological emergency. No consensus nomogram for FN risk assessment has been established. (3) Different assessment tools [e.g., Multinational Association for Supportive Care in Cancer (MASCC), the Clinical Index of Stable Febrile Neutropenia (CISNE) score model, and other tools] have been suggested to help stratify the risk of complications in patients with FN. However, current tools have limitations. The CISNE score model is useful to support decision-making, especially for patients with stable FN. (4) There are still some challenges, including the benefits of granulocyte colony stimulating factor treatment and the optimal antibiotic regimen in emergency management of FN. In view of the current reports, our group discusses the key points, new challenges, and management of CIN.

Febrile neutropenia management in cancer patients receiving anti-cancer agents' treatment: Deepening the search to offer the best care. A critical review follow-up

INTRODUCTION

Febrile neutropenia is a common complication in cancer patients. Emergency departments are in most countries the unique entry point to tertiary care. However, some challenges restrain emergency department professionals from complying with the protocol.

OBJECTIVE

To update the published review in 2018: "Critical review of emergency department management of chemotherapy complications in cancer patients", and explore improvement opportunities.

METHODS

MEDLINE, TROVE and SCOPUS databases were used to conduct a broad electronic literature search. Out of 74 articles yielded, nine responding to our questions were selected.

CONCLUSIONS

Febrile neutropenia management in cancer patients still represents a challenge for emergency departments that have difficulties to comply with international guidelines. It is critical to identify the best venue and which professionals to manage the target population. Appropriate care pathways and a more efficient tool to classify low and high risk patients, would improve clinical outcomes, while costs would be reduced.

Putting the Dissemination and Implementation in Infectious Diseases

Dissemination and implementation science seeks generalizable knowledge about closing the gap between clinical discovery and actual use in routine practice and public health. The field of infectious diseases enjoys an abundance of highly efficacious interventions (eg, antimicrobial agents, human immunodeficiency virus treatment) which are not adequately used in routine care, thereby missing critical opportunities to improve population health. In this article, we summarize salient features of dissemination and implementation science, reviewing definitions and methodologies for infectious diseases clinicians and researchers. We give examples of the limited use of dissemination and implementation science in infectious diseases thus far, suggest opportunities for application, and provide resources for interested readers to use and apply to their own research and practice.

Predicting in-hospital mortality of patients with febrile neutropenia using machine learning models

BACKGROUND

Febrile neutropenia (FN) has been associated with high mortality among adults with cancer. Current systems for early detection of inpatient FN mortality are based on scoring indexes that require intensive physicians' subjective evaluation.

OBJECTIVE

In this study, we leveraged machine learning techniques to build a FN mortality risk evaluation tool focused on FN admissions without physicians' subjective evaluation.

METHODS

We used the National Inpatient Sample and Nationwide Inpatient Sample (NIS) that included mortality data among adult inpatients who were diagnosed with FN during a hospital admission. Machine learning techniques that we compared included linear models (ridge logistic regression and linear support vector machine) and non-linear models (gradient boosting tree and neural network). The primary outcome for this study was death among individuals with a recorded FN admission. Model comparison was evaluated based on areas under the receiver operating characteristic curve (AUROC) and model performance was estimated using 30 % test set created via stratified split.

RESULTS

Our analysis detected 126,013 adult admissions within the NIS data that were diagnosed with FN, among which 5,856 were declared as deceased (4.6 %). Our machine learning results demonstrate linear models and non-linear models achieved areas under the receiver operating characteristic (AUROC) around 92 % in survival prediction.

CONCLUSIONS

We developed machine learning models that do not require physicians' subjective evaluation for FN mortality risk prediction.

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.

Standardizing Febrile Neutropenia Management: Antimicrobial Stewardship in the Hematologic Malignancy Population

Patients with febrile neutropenia (FN) often are subject to antibiotic and diagnostic test overuse. We sought to improve appropriate use of antimicrobials and diagnostic tests for patients with FN. We used a blended quality approach with Lean Six Sigma tools and iterative improvement of a clinical decision aid to guide providers through empirical antimicrobial selection and diagnostic evaluation of patients with FN during a yearlong period. We evaluated the incidence of nonadherence to best practice before, during, and after rollout of a clinical decision aid in conjunction with an educational initiative. At baseline, 71% of patients with FN had at least one critical deviation from best practice. During the project, the percentage decreased to 27.3%; 4 months after the project was completed, the percentage was 33.3% (P = .04). A clinical decision aid can improve adherence to best practices for the empirical management of FN.

Near-universal hospitalization of US emergency department patients with cancer and febrile neutropenia

Importance

Febrile neutropenia (FN) is the most common oncologic emergency and is among the most deadly. Guidelines recommend risk stratification and outpatient management of both pediatric and adult FN patients deemed to be at low risk of complications or mortality, but our prior single-center research demonstrated that the vast majority (95%) are hospitalized.

Objective

From a nationwide perspective, to determine the proportion of cancer patients of all ages hospitalized after an emergency department (ED) visit for FN, and to analyze variability in hospitalization rates. Our a priori hypothesis was that >90% of US cancer-associated ED FN visits would end in hospitalization.

Design

Analysis of data from the Nationwide Emergency Department Sample, 2006–2014.

Setting

Stratified probability sample of all US ED visits.

Participants

Inclusion criteria were: (1) Clinical Classification Software code indicating cancer, (2) diagnostic code indicating fever, and (3) diagnostic code indicating neutropenia. We excluded visits ending in transfer.

Exposure

The hospital at which the visit took place.

Main outcomes and measures

Our main outcome is the proportion of ED FN visits ending in hospitalization, with an a priori hypothesis of >90%. Our secondary outcomes are: (a) hospitalization rates among subsets, and (b) proportion of variability in the hospitalization rate attributable to which hospital the patient visited, as measured by the intra-class correlation coefficient (ICC).

Results

Of 348,868 visits selected to be representative of all US ED visits, 94% ended in hospitalization (95% Confidence Interval [CI] 93–94%). Each additional decade of age conferred 1.23x increased odds of hospitalization. Those with private (92%), self-pay (92%), and other (93%) insurance were less likely to be hospitalized than those with public insurance (95%, odds ratios [OR] 0.74–0.76). Hospitalization was least likely at non-metropolitan hospitals (84%, OR 0.15 relative to metropolitan teaching hospitals), and was also less likely at metropolitan non-teaching hospitals (94%, OR 0.64 relative to metropolitan teaching hospitals). The ICC adjusted for hospital random effects and patient and hospital characteristics was 26% (95%CI 23–29%), indicating that 26% of the variability in hospitalization rate was attributable to which hospital the patient visited.

Conclusions and relevance

Nearly all cancer-associated ED FN visits in the US end in hospitalization. Inter-hospital variation in hospitalization practices explains 26% of the limited variability in hospitalization decisions. Simple, objective tools are needed to improve risk stratification for ED FN patients.

Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments

IMPORTANCE

Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management.

OBJECTIVE

To provide a benchmark description of patients who present to the ED with active cancer.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018.

MAIN OUTCOMES AND MEASURES

The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified.

RESULTS

Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics.

CONCLUSIONS AND RELEVANCE

This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

Prognostic value of procalcitonin and lipopolysaccharide binding protein in cancer patients with chemotherapy-associated febrile neutropenia presenting to an emergency department

INTRODUCTION

Cancer patients with chemotherapy-induced febrile neutropenia are a heterogeneous group with a significant risk of serious medical complications. In these patients, the Multinational Association for Supportive Care in Cancer (MASCC) score is the most widely used tool for risk-stratification. The aim of this prospective study was to analyse the value of procalcitonin (PCT) and lipopolysaccharide binding protein (LBP) to predict serious complications and bacteraemia in cancer patients with febrile neutropenia, compared with MASCC score.

MATERIALS AND METHODS

Data were collected from 111 episodes of febrile neutropenia admitted consecutively to the emergency department. In all of them, MASCC score was calculated and serum samples were collected for measurement of PCT and LBP by well-established methods. The main and secondary outcomes were the development of serious complications and bacteraemia, respectively.

RESULTS

A serious complication occurred in 20 (18%) episodes and in 16 (14%) bacteraemia was detected. Areas under the receiver operating characteristic curve (ROC AUC) of MASCC score, PCT and LBP to select low-risk patients were 0.83 (95% confidence interval (CI): 0.74 - 0.89), 0.85 (95% CI: 0.77 - 0.91) and 0.70 (95% CI: 0.61 - 0.78), respectively. For bacteraemia, MASCC score, PCT and LBP showed ROC AUCs of 0.74 (95% CI: 0.64 - 0.82), 0.86 (95% CI: 0.78 - 0.92) and 0.76 (95% CI: 0.67 - 0.83), respectively.

CONCLUSION

A single measurement of PCT performs similarly as MASCC score to predict serious medical complications in cancer patients with febrile neutropenia and can be a useful tool for risk stratification. Besides, low PCT concentrations can be used to rule-out the presence of bacteraemia.

Diagnosis and Management of Oncologic Emergencies

Oncologic emergencies may be seen in any emergency department and will become more frequent as our population ages and more patients receive chemotherapy. Life-saving interventions are available for certain oncologic emergencies if the diagnosis is made in a timely fashion. In this article we will cover neutropenic fever, tumor lysis syndrome, hypercalcemia of malignancy, and hyperviscosity syndrome. After reading this article the reader should be much more confident in the diagnosis, evaluation, and management of these oncologic emergencies.

Critical review of emergency department management of chemotherapy complications in cancer patients

INTRODUCTION

Recent worldwide advances in cancer therapies have resulted in an increased number of people receiving chemotherapy in ambulatory care settings. In Spain, emergency departments are the single point of entry to acute inpatient services and they play a pivotal role in the management of chemotherapy complications. Little research exists in patterns of emergency department utilisation by oncology patients with chemotherapy-related complications. However, it is important for the oncology patients and the healthcare system to gain understanding in the disease pathway and the organisational factors influencing the quality of care.

METHODS

This critical review's main aims were to describe the clinical characteristics of patients who presented to an emergency department after chemotherapy treatment as reported in international literature; to map reported patterns of care in emergency department access; and quality of care exploring the management of febrile neutropenic patients described in the literature, against best practice guidelines.

RESULTS

The search strategy yield 701 articles from MEDLINE, TROVE and SCOPUS and 26 were included. The review combines systematic reviews, observational, cross-sectional case-control studies and randomised control trials.

CONCLUSION

All articles showed areas and opportunities for improvement in the management of this population, especially with regard to time from triage to antibiotic administration in febrile neutropenic patients.

Integrative omics to detect bacteremia in patients with febrile neutropenia

BACKGROUND

Cancer chemotherapy-associated febrile neutropenia (FN) is a common condition that is deadly when bacteremia is present. Detection of bacteremia depends on culture, which takes days, and no accurate predictive tools applicable to the initial evaluation are available. We utilized metabolomics and transcriptomics to develop multivariable predictors of bacteremia among FN patients.

METHODS

We classified emergency department patients with FN and no apparent infection at presentation as bacteremic (cases) or not (controls), according to blood culture results. We assessed relative metabolite abundance in plasma, and relative expression of 2,560 immunology and cancer-related genes in whole blood. We used logistic regression to identify multivariable predictors of bacteremia, and report test characteristics of the derived predictors.

RESULTS

For metabolomics, 14 bacteremic cases and 25 non-bacteremic controls were available for analysis; for transcriptomics we had 7 and 22 respectively. A 5-predictor metabolomic model had an area under the receiver operating characteristic curve of 0.991 (95%CI: 0.972,1.000), 100% sensitivity, and 96% specificity for identifying bacteremia. Pregnenolone steroids were more abundant in cases and carnitine metabolites were more abundant in controls. A 3-predictor gene expression model had corresponding results of 0.961 (95%CI: 0.896,1.000), 100%, and 86%. Genes involved in innate immunity were differentially expressed.

CONCLUSIONS

Classifiers derived from metabolomic and gene expression data hold promise as objective and accurate predictors of bacteremia among FN patients without apparent infection at presentation, and can provide insights into the underlying biology. Our findings should be considered illustrative, but may lay the groundwork for future biomarker development.