Goodman Lindsey Martin, Estfan Bassam, Montero Alberto, Kunapareddy Girish, Lau Jessica, Gallagher Erika, Best Carolyn, Tripp Barb, Moeller Machelle, Bolwell Brian, Stevenson James
Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
J Oncol Pract. 2017 Mar;13(3):e259-e265. doi: 10.1200/JOP.2016.017277. Epub 2017 Feb 7.
Neutropenic fever (NF) is an oncologic emergency and has resulted historically in inpatient management. The Multinational Association for Supportive Care in Cancer (MASCC) score can be used to identify patients with NF at a low risk of complications who can be managed safely as outpatients. Despite established guidelines supporting outpatient management of low-risk neutropenic fever (LRNF), provider awareness is low, and inpatient admission for intravenous antibiotics continues to be standard of care.
Inpatient provider algorithm implementation and education began in the second quarter of 2014. Providers calculated MASCC scores for patients with nonleukemia hematologic malignancies and solid tumors at admission. Data were collected in a prospectively maintained registry. Patients identified as low risk by MASCC score were placed under observation and started on oral antibiotics. If exclusion criteria and social barriers were not identified, discharge within 48 hours was planned.
Eighty-three patients with NF were admitted to the Taussig Cancer Institute inpatient oncology unit between November 2014 and June 2015. Fifty-three patients (64%) had LRNF by MASCC score. Patients with LRNF had an average length of stay of 3.3 days, compared with 6.2 days in our historical cohort. Sixteen patients (30%) were discharged within 24 hours. Only two patients with LRNF had a culture-proven infection, both Enterococcus urinary tract infections. Three patients required nonelective readmission. There were no deaths caused by NF.
This pilot study demonstrates that a formal algorithm for LRNF management combined with provider education can improve current inpatient standard of care and length of stay without an increase in morbidity.
中性粒细胞减少性发热（NF）是一种肿瘤急症，历来需要住院治疗。癌症支持治疗多国协会（MASCC）评分可用于识别并发症风险较低的NF患者，这些患者可作为门诊患者安全管理。尽管有既定指南支持对低风险中性粒细胞减少性发热（LRNF）进行门诊管理，但医护人员的认知度较低，静脉使用抗生素的住院治疗仍是标准治疗方式。
2014年第二季度开始实施住院医护人员算法并开展相关教育。医护人员在患者入院时为非白血病血液系统恶性肿瘤和实体瘤患者计算MASCC评分。数据收集于前瞻性维护的登记册。通过MASCC评分确定为低风险的患者接受观察并开始口服抗生素治疗。如果未发现排除标准和社会障碍，则计划在48小时内出院。
2014年11月至2015年6月期间，83例NF患者入住陶西格癌症研究所住院肿瘤科。53例患者（64%）通过MASCC评分被判定为LRNF。LRNF患者的平均住院时间为3.3天，而我们历史队列中的患者为6.2天。16例患者（30%）在24小时内出院。只有2例LRNF患者有经培养证实的感染，均为肠球菌尿路感染。3例患者需要非选择性再次入院。没有因NF导致的死亡。
这项初步研究表明，LRNF管理的正式算法与医护人员教育相结合，可以改善当前的住院治疗标准和住院时间，而不会增加发病率。
