Evaluation of a Risk Stratification Guideline for the Treatment of Neutropenic Fever in Oncology Patients

Abstract

BackgroundNeutropenic fever (NF) is a serious complication of chemotherapy. Approximately 23% of NF cases are related to bacteremia, with higher mortality attributed to infections caused by Pseudomonas aeruginosa. Therefore, empiric anti-pseudomonal (AP) coverage is critical for patients with NF. However, no recommendations exist as to which AP agent is preferred. Traditionally at Froedtert Hospital, meropenem was prescribed as empiric therapy for NF despite a low incidence of multidrug resistant (MDR) pathogens. In June 2016, Froedtert Hospital implemented guidelines for the treatment of NF to guide initial AP antibiotic selection based on risk factors for MDR gram-negative infections. Risk stratification reserves broadest spectrum antimicrobials (eg, meropenem) for patients at highest risk of MDR organisms.MethodsA retrospective chart review was completed to evaluate NF treatment pre-guideline (Jan 1-June 30, 2015) and post-guideline implementation (June 23- Dec 31, 2016). All patients ≥18 years old, admitted to Froedtert Hospital that met NF definition criteria were included.ResultsA total of 79 patients in the pre-guideline implementation group (pre-group) and 91 patients in the post-guideline implementation group (post-group) were included. In the pre-group, only 26 (32.8%) patients would have met criteria to receive meropenem, however 71 (89.8%) received it. In comparison, in the post-group, 29 (41.8%) patients qualified to receive meropenem based on risk-stratification and 8 patients (8.8%) received it, due to primary teams opting for non-carbapenem APs despite meeting criteria for meropenem. In the post-group, there were 4 cases of infections with a MDR organism requiring meropenem. All 4 patients met guideline criteria to receive meropenem (2 patients received meropenem, 2 did not due to guideline noncompliance). Therefore, the incidence of appropriate empiric AP therapy recommended by the NF guideline was 100%. 30-day all-cause mortality was 17.7% in the pre-group and 15.5% in the post-group.ConclusionAppropriate use of a NF risk stratification tool resulted in a significant reduction in unnecessary AP carbapenem use without compromising antimicrobial coverage of isolated organisms or patient outcomes.Disclosures All authors: No reported disclosures.