Assessing adherence to the IDSA guideline in managing Neutropenic Fever in a community hospital

From the 2018 HVPAA National Conference

Naveed Jan (Crozer-Chester Medical Center), Karandeep Bumrah (Crozer-Chester Medical Center), Fnu Aparna (Crozer-Chester Medical Center), Taranjit Gill (Crozer-Chester Medical Center), Aishwarya Kuchikulla (Crozer-Chester Medical Center)

Background

Neutropenic fever is one of the hematological emergencies responsible for significant morbidity and mortality. Without early antibiotics, it has a mortality rate of 70%. MASCC scoring system is a well-validated risk stratifying tool which can be used to triage these patients in an appropriate medical setting.

Objectives

The aim of our study was to recognize the deficiencies in management and to assess the adherence to the standard guidelines set by IDSA to manage the patients with Neutropenic Fever. Also, to assess utilization of the MASCC scoring system at presentation in triaging these patients to guide further management.

Methods

This retrospective observational study was done on by chart review on patients treated as Neutropenic Fever at our hospital from December 2012 through October 2015. The study population was identified using the ICD-9 code for neutropenia and subsequently, each chart was reviewed to identify patients with ANC <500 in the setting of chemotherapy and febrile illness. A total of 358 patient charts were reviewed and 141 patients were included in the final study after exclusions. In the first part of the study, MASCC score for each patient was calculated using QxMD online calculator to determine the appropriateness of hospitalization. In the second part of the study, use of types of antimicrobial agents, acquisition of pre-antibiotic cultures, use of the colony stimulating agents, utilization of environmental precaution, and mortality and morbidity of the illness was determined.

Results

The study population was comprised of 73 males and 67 females with age range from 32 to 90 years. Hematological malignancies (36.5%), lung cancer (15%), breast cancer (10.5%) and colorectal malignancies (10.5%) were the top four oncological diagnoses. Subjective or objective record of fever was present in 54.6% (87/141) of the study population. Eighty-two percent patients (116/141) had a MASCC score < 21 (high risk) while 18% patients (25/141) had a MASCC score of ≥21 (low risk). Antipseudomonal coverage was appropriately given in 81% (114/141) of the patients. Sub-optimal coverage with non-pseudomonal agents was seen in 19% (27/141) of the patients while 5% of the patients did not have blood cultures drawn at the time of admission. MRSA coverage with vancomycin was given to 50% (71/141) of the patients without clear indications. A colony-stimulating agent was given to 72% (102/141) of the patients. Environmental precautions were ordered in 54% of the patients.

Conclusion

This study was designed to investigate compliance with IDSA guidelines and to identify deficiencies in the management of patients with the neutropenic fever in a community hospital setting. Utilization of the MASCC score should be used as a tool to risk stratify patients and to avoid unnecessary hospitalization. Low-risk patients with a MASCC score ≥ 21 should be first managed in an outpatient setting. Use of an anti-pseudomonal agent as empiric therapy is essential and must be considered in every neutropenic fever patient. Our study had an inpatient mortality rate of 14% thus supporting that proactive and guide-line based management is paramount in the treatment of patients with neutropenic fever.

Implications for the Patient

MASCC score system is well validated risk stratification tool which can be used to prevent unnecessary hospitalization. Use of an anti-pseudomonal agent in managing neutropenic fever is pivotal. Avoidance of excessive use of the MRSA coverage without clear indication.

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