Retrospective study of the evaluation and management of febrile neutropenia in cancer patients in a tertiary center.

Abstract

e19100 Background: Febrile neutropenia is a medical emergency often managed by internists, but adherence to guidelines has not been well-described. We aimed to describe care and outcomes of a retrospective cohort of patients hospitalized with febrile neutropenia at a single tertiary care hospital. Methods: We included adults ≥18 years old who had a cancer diagnosis and required hospital admission for a principal diagnosis of fever and neutropenia (ANC < 500) from October 2015 - April 2019. We reviewed records to identify demographics, cancer diagnosis and stage, and outcomes, including death. Results: We included 193 patients; all were cared for by hospitalists. About half (52%) were classified as high risk [ < 21 Multinational Association of Supportive Care in Cancer (MASCC)score], but only 1 patient had a documented MASCC score in hospital progress notes. The majority of patients were female (55%) and white (84%). Twenty-three percent had a stage IV diagnosis. Most (89.1%) patients were within their first chemotherapy cycle, and 23% received GCSF. Approximately half (47%) had solid tumors; the remainder had hematologic malignancies. About one quarter (27%) had positive blood cultures (of these, 43.4 % were gram positive cocci (GPC); 49.1% were gram negative rods (GNR)). Most patients received empiric coverage for GPC and GNR: 82% received cefepime and 42% received empiric MRSA coverage. Few patients had cultures positive for resistant organisms such as MRSA (n = 3) or pseudomonas (n = 4). Hematology/Oncology was consulted for most (82%) cases. Inpatient mortality occurred in 12% of patients. Compared to those who survived, patients who died had lower MASCC score 13.9 (vs. 19.1) and were more likely to receive critical care therapies during hospitalization (70% vs. 14%). Few patients (n = 24, 12%) had documented goals of care (GOC) discussions. Conclusions: Although MASCC is predictive of outcomes, internists caring for patients with fever and neutropenia do not document this score. Hospitalist-focused education efforts about MASCC score could improve care. Few patients had documented GOC discussions. Oncologists should maintain good communication with internal medicine colleagues, who may be hesitant to address GOC in patients receiving chemotherapy.