Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department

Abstract

Introduction: The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED.

Methods: We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses.

Results: We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28).

Conclusion: An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.

Fig 1. Receiver operating characteristics curve.

Accuracy of the MASCC risk-index in predicting the absence of complication for neutropenic patients in the ED. Specificity and sensitivity are indicated for each threshold. AUC area under the curve, MASCC Multinational Association of Supportive Care in Cancer.

Fig 2. Boxplot.

Time to antibiotics initiation in the ED depending on the outcome (ICU or death during hospital stay). Median and IQR were 92 [48–150] min for those who did not meet the outcome and 66 [30–135] min for those who did with no statistical difference according to the Wilcoxon Mann Whitney test (p = 0.097).

Fig 3. Kaplan-Meier curves of the ICU free survival during 90 days from ED presentation depending on the appropriateness of the antibiotic regimen initiated in the ED.