(074) Evaluating Safety and Efficacy of Empiric Antimicrobial De-escalation for Febrile Neutropenia in Patients with Malignant Hematology or Undergoing Hematopoietic Stem Cell Transplantation

Poster Abstract:

Background: Febrile neutropenia is a serious complication of chemotherapy that causes significant stress on the patient and is associated with an increase in morbidity and mortality for cancer patients. In 2011, the Infectious Diseases Society of America (IDSA) recommended in patients with unexplained fever, the initial regimen be continued until there are clear signs of marrow recovery which is defined as an increasing ANC that > 500 cells/mm3. In the last decade, there has been a significant shift in the management approach to febrile neutropenia, with a variety of modifications based on the results of numerous clinical trials. The results from these trials showed that antibiotic de-escalation and discontinuation resulted in a decreased usage of intravenous antipseudomonal antibiotics, a decrease in antibiotic-free period, and fewer episodes of C. difficile colitis, without adversely impacting patient outcomes. In July 2022, UIHC implemented guidance for cancer patients with febrile neutropenia through the creation of a neutropenic fever de-escalation pathway.

Objectives: evaluate the clinician utilization of our institutional pathway for antibiotic de-escalation in the setting of ongoing neutropenia and identify the impact of an antibiotic de-escalation protocol on patient outcomes.

Methods: single-center, retrospective, observational, quasi-experimental that was approved by the Institutional Review Board at the University of Iowa Hospitals and Clinics. Between July 2021 and July 2023, patients were included if they were 18 years of age or older. If they had an ICD-10 code for acute myeloid leukemia; acute lymphocytic leukemia, lymphoma, who underwent induction chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation. Patients who were afebrile but remained neutropenic without signs of active infection will also be included. Patients were excluded if they had chronic neutropenia defined as neutrophils ≤ 500/mm3 for 3 months or more; if they were pregnant, breastfeeding. Patients who received any broad-spectrum antimicrobial therapy from the outside institution before admitting to UIHC will also be excluded. A cohort of patients meeting the same criteria above but receiving antibiotics before the implementation of febrile neutropenia protocol will serve as the control group in the study. The two cohorts will be analyzed in a 1:1 ratio (pre:post implementation). The primary outcome is to evaluate the reinfection rate and the subsequent need for re-escalation of antibiotics. The secondary outcome is to evaluate incidence of MDR [VRE, MRSA, ESBL] pathogen, incidence of C.diff infection, antibiotic free period/duration of broad-spectrum antimicrobials, infection-related ICU admission, hospital LOS, all-cause mortality.
Results, discussion, conclusions: pending.

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