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Emergency Department Management of Patients With Febrile Neutropenia: Guideline Concordant or Overly Aggressive?
Author(s) -
Baugh Christopher W.,
Wang Thomas J.,
Caterino Jeffrey M.,
Baker Olesya N.,
Brooks Gabriel A.,
Reust Audrey C.,
Pallin Daniel J.
Publication year - 2017
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.13079
Subject(s) - medicine , guideline , emergency department , concordance , febrile neutropenia , confidence interval , emergency medicine , relative risk , neutropenia , intensive care medicine , chemotherapy , pathology , psychiatry
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 emergency department (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 January 2010 to December 2014. Using electronic medical records, we identified all visits by patients with fever and an absolute neutrophil count of <1000 cells/mm 3 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 versus 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% confidence interval [CI] = 63% to 77%). Management was guideline discordant in 43 (98%, 95% CI = 88% to 100%) of low‐risk patients versus 9 (7%, 95% CI = 3% to 13%) of high‐risk patients (relative risk [RR] = 14, 95% CI = 7.5 to 26). Of 52 guideline‐discordant cases, 36 (83%, 95% CI = 72% to 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.