Febrile Neutropenia Allison 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/mm 3  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 ;52(4):  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 ;31(6):  Febrile Neutropenia. In DynaMed [database online]. EBSCO Information Services. Updated March 17, Accessed April 15,