Implementation of risk stratified antibiotic therapy for neutropenic fever: what are the risks?

Potential reduction of hospital stay length with outpatient management of low-risk febrile neutropenia in a regional cancer center

Background

Febrile neutropenia is a serious complication of chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score identifies patients at low risk of serious complications. Outpatient management programs have been successfully piloted in other Australian metropolitan cancer centers.

Aim

To assess current management of febrile neutropenia at our regional cancer center and determine potential impacts of an outpatient management program.

Method

We performed a retrospective review of medical records for all patients admitted at our regional institution with febrile neutropenia between 1 January 2016, and 31 December 2018. We collected information regarding patient characteristics, determined the MASCC risk index score, and if low risk, we determined the eligibility for outpatient care and potential reduction in length of stay and cost benefit.

Results

A total of 98 hospital admissions were identified. Of these, 66 had a MASCC low‐risk index score. Fifty‐eight patients met the eligibility criteria for outpatient management. Seventy‐one percent were female. The most common tumor type was breast cancer. Forty‐eight percent were treated with curative intent. The median length of stay was 3 days. The median potential reduction in length of stay for each admission was 2 days. The total potential reduction in length of stay was 198 days. No admission resulted in serious complications.

Conclusion

This review demonstrates a significant number of hospital admission days can be avoided. We intend to conduct a prospective pilot study at our center to institute an outpatient management program for such low‐risk patients with potential reduction in hospital length of stay. This will have significant implications on health resource usage, service provision planning, and patient quality of life.

The role of temperature in the detection and diagnosis of neutropenic sepsis in adult solid tumour cancer patients receiving chemotherapy

PURPOSE

The primary aim of this study was to examine the value of temperature as a diagnostic and prognostic indicator of infection and sepsis in neutropenic patients. A secondary aim was to gain insight into the presenting symptoms reported by these patients at home or on their initial admission assessment.

METHODS

A cohort study was carried out using a case note review of 220 emergency admissions to a regional cancer centre. All participants were neutropenic and were diagnosed with infection on admission. The main outcome measures were relationships between Early Warning Scores and temperature values at home, on admission and during the hospital stay.

RESULTS

22% of patients who became acutely unwell did not have a fever. Pearson correlations showed only small associations between highest temperature value at any time point and highest early warning scores (r(202) = 0.176, P = .012). Temperature at home (B = 0.156, P = .336) and temperature on admission (B = 0.200, P = .052) did not predict highest Early Warning Scores.

CONCLUSIONS

Body temperature is not a consistently reliable diagnostic or prognostic indicator for outcomes in patients with neutropenia and symptoms of infection. It can assist with early presentation and recognition of infection in many neutropenic patients. However, over-reliance on temperature risks missing the opportunity for early detection and treatment.

Developing a tool for nurses to assess risk of infection in pediatric oncology patients in China: a modified Delphi study

Infections are identified as the most common preventable cause of death in pediatric oncology patients. Assessing and stratifying risk of infections are essential to prevent infection in these patients. To date, no tool can fulfill this demand in China. This study aimed to develop a nursing work-based and Chinese-specific tool for pediatric nurses to assess risk of infection in oncology patients. This research was a modified Delphi study. Based on a literature review, a 37-item questionnaire rating on a 0–5 scale was developed. Twenty-four experts from 8 hospitals in 6 provinces of China were consulted for three rounds. Consensus for each item in the first round was defined as: the rating mean was > 3 and the coefficient of variation (CV) was < 0.5. Consensus for each item in the second round was defined as CV < 0.3. Consensus among experts was defined as: P value of Kendall's coefficient of concordance (W) < 0.05. After three rounds of consultation, a two-part tool was developed: the Immune Status Scale (ISS) and the Checklist of Risk Factors of Infection (CRFI). There were 5 items in the ISS and 14 in the CRFI. Based on the ISS score, nurses could stratify children into the low-risk and high-risk groups. For high-risk children, nurses should screen risk factors of infection every day by the CRFI, and twice weekly for low-risk children. Further study is needed to verify this tool's efficacy.

[Mortality of hematology-oncology patients with neutropenia in intensivecare]

BACKGROUND

Febrile neutropenia remains one of the most common reasons for hospital admission of patients with underlying oncologic disease. These patients have an up to 10-fold increased risk of developing sepsis, which often leads to these patients being transferred to the intensive care unit (ICU). The survival of neutropenic patients with sepsis in particular has improved in recent years, due to advanced therapy in intensive care (surviving sepsis campaign); however few large international studies of neutropenic cancer patients in the ICU are available.

METHODS

In a retrospective study, 59 episodes of neutropenic cancer patients in the internal medicine ICU at the University Hospital of Cologne over a period of 2 years were analyzed.

RESULTS

Pneumonia with or without sepsis are the main admission diagnoses of neutropenic cancer patients in the ICU. The mortality rate of these patients is very high (50.8 %). Pneumonia and sepsis, stem cell transplantation, mechanical ventilation, and acute renal failure with or without dialysis are correlated with mortality.

CONCLUSION

Cancer patients should be admitted immediately to the ICU if they have signs of sepsis for early monitoring and treatment. Neutropenic patients have an increased risk for infectious complications and a risk for sepsis with higher mortality rates.