Management of febrile neutropenia in malignancy using the MASCC score and other factors: Feasibility and safety in routine clinical practice.

Abstract

The current standards for empirical broad-spectrum intravenous antibiotic (AB) treatment, combined with hospitalization, are cautious and safe, but lead to over-treatment of a substantial group of patients. We need to validate parameters to identify these low-risk febrile-neutropenia (FN) patients, who could then be safely treated in an outpatient setting with minimal/no AB treatment. A retrospective analysis for validation of a risk-assessment model in FN patients was done on a patient population from January 2007 to December 2008. Inclusion criteria were a histological diagnosis of malignancy, FN secondary to chemotherapy, absolute-neutrophil-count of ≤ 500/μl, axillary temperature of ≥ 38°C, and age ≥ 14 years. Other clinical and laboratory parameters were explored for risk stratification during the FN episodes. Receiver-operating characteristic curves were used to find the threshold value, an Chi-square analysis was done to find the association between the outcome and the parameters. A total of 178 FN episodes were documented; 22 in solid tumors and 156 in hematolymphoid malignancies. Culture positivity was documented in 59 episodes; peripheral blood was the most common source, with Escherichia coli being the most common organism identified. Risk stratification was done using the Multinational Association of Supportive Care in Cancer (MASCC) risk-index score. The association between the MASCC score and risk stratification could not be established (P = not significant) at a score of ≤ 21; however, it was found to be significant at a score of ≤ 18. The total number of complications was 23 (sepsis 22, mortality 23). Other factors found to be significantly associated with a high risk of complications in the univariate analysis were, mucositis (P = 0.03), maximum temperature ≥ 103°F (P = 0.01), tachycardia (P < 0.001), tachypnea (P = <0.001), age (P = 0.006), high dose of steroid (P < 0.001), total duration of fever (≥ 2.5 days (for which sensitivity (S) and specificity (Sp) were 87 and 81%, respectively), serum-creatinine (≥ 0.45 mg%, S = 100%, Sp = 97%), serum-bilirubin (≥ 0.5 mg/dl, S = 100%. Sp = 90%), requirement of second-line antibiotics (P = 0.02), intensive-care (P ≤ 0.001), ventilatory support (P < 0.001), and requirement of packed cell (PC) transfusion (P = 0.02). In the multivariate analysis, mucositis (P = 0.02), HD steroid use (P = 0.026), and PC requirement (0.026) were identified as independent variables. The MASCC risk-index score was found to be meaningful at a score of ≤ 18. Other clinical and laboratory parameters were found to have a strong association with risk stratification in cancer patients during FN episodes.