Febrile NeutropeniaAllison Ferrara, MD

Princeton Baptist Medical Center

Baptist Health Systems Alabama

Introduction Topic

Cancer patients with fever and neutropenia Review the time from complete blood count with differential (CBC)

result to administration of first antibiotic Include blood cultures to be drawn prior to administration of first

antibiotic Two hour goal for task completion

Structure and Purpose To look at course of treatment of cancer patients with febrile

neutropenia from time of CBC result to administration of first antibiotic, including time of blood cultures, to identify opportunities for improvement in care

Literature Review Neutropenic fever

Oncologic medical emergency requiring prompt assessment and administration of antibiotics

Most common in patients receiving cytotoxic chemotherapy Significant morbidity and mortality Bacteremia is most commonly identified cause of infection

Current Guidelines Receive blood cultures immediately

Collect 2 sets prior to antibiotic administration Receive empiric antibiotic therapy within 2 hours of presentation

Literature Review (cont.) Antibiotic Selection

IV agent with anti-pseudomonal activity is first-line monotherapy for high-risk patients requiring hospitalization Piperacillin-tazobactam Cefepime Meropenem Imipenem-cilastatin

Secondary antibiotics depending on clinical presentation and patient’s history Aminoglycosides Vancomycin Empiric antifungal options

Methods Data abstracted from EPIC utilizing ICD-9 codes for fever

and neutropenia Capture and analyze

Time of CBC to first antibiotic administration Blood cultures collected prior to first antibiotic administration Type of antibiotic administered

Criteria for Study Neutropenia defined as ANC ≤1500 cells/mm3

Any form of malignancy Fever >100.4 Collection time of CBC Collection time of blood cultures Time of administration of first antibiotic Type of antibiotic administered

Guidelines National Comprehensive Cancer Network (NCCN) Infectious Disease Society of America (IDSA) American Society of Clinical Oncology (ASCO)

Summary of Findings 65 neutropenic patients admitted to PBMC from March 2012

to May 2014 47 with diagnosis of some form of cancer

20 with fever at time at time of admission

60% of febrile neutropenic patients with cancer diagnosis received blood cultures prior to antibiotic administration AND within two hour window

45% received antibiotics within two hours 15% of total patients received appropriate antibiotics and had

blood cultures collected prior to antibiotic administration in 2 hour time window

Conclusion PBMC is above national benchmark of 2 hours for time of

administration of appropriate empiric antibiotic therapy to cancer patients presenting with neutropenic fever

Goals & Outcomes Goal

To identify areas for improvement in process of treating neutropenic patients

Outcome Patients admitted with

neutropenic fever are not receiving timely and appropriate antibiotic therapy

Antibiotic administration is outside the national benchmark of 2 hours

Not consistently using anti-pseudomonal agents

Recommendations 1. Nursing education on need to give anti-pseudomonal

antibiotic first Emphasis on need to give antibiotic as soon as aware of febrile

neutropenic status Emphasize importance to nursing and lab staff on need for

immediate physician notification of critical lab values 2. Encourage use of febrile neutropenia order-set amongst

physicians 3. Repeat study from March 2015 to 2017 to assess success

of implemented changes and education efforts

References Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA,

et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis. Feb 15 2011;52(4):427-31.

Flowers CR, Seidenfeld J, Bow EJ, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. Feb 20 2013;31(6):794-810.

Febrile Neutropenia. In DynaMed [database online]. EBSCO Information Services. http://web.a.ebscohost.com/dynamed/. Updated March 17, 2014. Accessed April 15, 2014.