ED Management of Patients with Febrile Neutropenia: Guideline Concordant or Overly Aggressive?
Acad Emerg Med. 2016 Sep 9;
Authors: Baugh CW, Wang TJ, Caterino JM, Baker ON, Brooks GA, Reust AC, Pallin DJ
OBJECTIVES: The Infectious Diseases Society of America and the American Society of Clinical Oncology recommend risk stratification of patients with febrile neutropenia (FN), and discharge with oral antibiotics for low-risk patients. We studied guideline concordance and clinical outcomes of FN management in our ED.
METHODS: Our urban, tertiary-care teaching hospital provides all emergency and inpatient services to a large comprehensive cancer center. We performed a structured chart review of all FN patients seen in our ED from 01/2010-12/2014. Using electronic medical records, we identified all visits by patients with fever and an absolute neutrophil count <1000 cells/μL, and then included only patients without a clear source of infection. Following national guidelines, we classified patients as low- or high-risk, and assessed guideline concordance in disposition and parenteral vs. oral antibiotic therapy by risk category as our main outcome measure.
RESULTS: Of 173 qualifying visits, we classified 44 (25%) as low-risk and 129 (75%) as high-risk. Management was guideline-concordant in 121 (70%, 95%CI 63-77%). Management was guideline discordant in 43 (98%, 95%CI 88-100) of low-risk patients, versus 9 (7%, 95%CI 3-13) of high-risk patients (relative risk [RR] 14, 95%CI 7.5-26). Of 52 guideline-discordant cases, 36 (83%, 95%CI 72-93) involved low-risk cases with treatment that was more aggressive than recommended.
CONCLUSIONS: Guideline concordance was low among low-risk patients, with management tending to be more aggressive than recommended. Unless data emerge that undermine the guidelines, we believe that many of these hospitalizations and parenteral antibiotic regimens can be avoided, decreasing the risks associated with hospitalization, while improving antibiotic stewardship and patient comfort. This article is protected by copyright. All rights reserved.
PMID: 27611638 [PubMed - as supplied by publisher]