Antimicrobial Management and Outcomes of Cancer Patients with Febrile Neutropenia Admitted to General Internal Medicine at Toronto General Hospital
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Background: Febrile neutropenia (FN) is a medical emergency that can lead to significant morbidity and mortality for oncology patients. As recommended by the Infectious Diseases Society of America (IDSA) for Antimicrobial Stewardship Program (ASP) interventions, developing facility-specific guidelines for FN management in hematology-oncology patients can reduce unnecessary antibiotic use without adverse outcomes.
Objective: At the University Health Network (UHN), guideline-recommended empiric antimicrobials are piperacillin/tazobactam plus aminoglycoside in higher-risk FN patients, and cefazolin plus aminoglycoside in lower-risk FN patients. Meropenem is an accepted alternative for patients with self-reported penicillin allergies. The aim of this study is to determine if patients admitted to the General Internal Medicine (GIM) service at Toronto General Hospital (TGH) for febrile neutropenia were given guideline specified empiric antimicrobials within 48 hours of admission for oncology patients admitted with febrile neutropenia.
Methods: A retrospective observational study was conducted in patients admitted with FN from July 1, 2016 to June 30, 2017. Patients were classified as either low-risk or high-risk according to cancer diagnosis and chemotherapy received. The primary outcome was the proportion of patients administered guideline-specified empiric antimicrobials within 48 hours of admission to GIM. Secondary outcomes were the proportion of patients whose empiric antimicrobials were active against pathogens isolated, the rate of antimicrobial adverse events, and the 30-day readmission rate.
Results: One hundred patients were included, of which 34% (34/100) were classified as low-risk FN and 66% (66/100) as high-risk FN. Antimicrobial management was guideline-concordant in 59% (59/100) of all admissions. In the low-risk group, guideline concordance was 35% (12/35), and in the high-risk group, 71% (47/66). Source of infection was identified in 50% (50/100) of cases, and empiric antimicrobials were active against 94% (17/18) of the pathogens isolated. Antimicrobial adverse events occurred in 16% (16/100) of admissions, and 30-day readmission rate was 23% (23/100).
Conclusion: Guideline concordance in the antimicrobial management of FN patients was low in GIM at TGH at 59%. Future qualitative studies to identify factors influencing antimicrobial prescribing behaviours to improve knowledge translation are warranted.
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