BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.
METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.
RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.
CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.