Kanser Hastaları ve Hematopoetik Kök Hücre Nakli Alıcılarında Febril Nötropeni Tanı ve Tedavi Protokolüne Uyumun Değerlendirilmesi ve Artırılması
Özet
Tas, Z. Evaluatıon And Improvement of Complıance Wıth The Dıagnosıs And Treatment Protocol Of Febrıle Neutropenıa In Cancer Patıents And Hematopoıetıc Stem Cell Transplant Recıpıents. Hacettepe Unıversıty Faculty Of Medıcıne, Infectıous Dıseases And Clınıcal Mıcrobıology Specıalızatıon Thesıs. Ankara, 2021.
The institutional approach for the management of febrile neutropenia (FN) which was prepared in collaboration of Infectious Diseases, Oncology, and Hematology Departments was released as a written guideline in 2017. The aim of this study was to investigate the compliance with the institutional approach and influence of a written guideline on the compliance of local protocol for the management of FN in patients with hematological malignancy, solid tumor, and recipients of hematopoietic stem cell transplantation (HSCT). A total of 227 patients with FN whose records were provided by the Infection Control Committee Antimicrobial Stewardship Subcommittee were investigated in terms of compliance with antimicrobial prophylaxis, screening, and diagnostic tests, and empirical antibacterial treatment between April 2016 and January 2019. FN was detected in 91 (40,1%) patients before the release of FN guideline (period 1) and FN was detected in 136 (59,9%) patients after the release of local FN guideline (period 2). One hundred seventy-five patients had hematological malignancy and 49 had a solid tumor. Twenty-six patients had received allogeneic HSCT and 40 had received autologous HSCT. The demographic characteristics of the patients with FN such as age, gender, type of malignancy, and receipt of HSCT were similar when two periods were compared. The full compliance (indication, dosage, and duration) rate of antibacterial prophylaxis was 38,3% and the full compliance rate of antifungal prophylaxis (indication, type of the drug, dosage, and duration) was 14,1%. There was no difference in the compliance rates of antibacterial and antifungal prophylaxis when two periods were compared. There were 84 patients in whom galactomannan (GM) antigen screening was recommended by the local guideline. The rate of compliance with GM antigen screening was similar in two periods (Period 1 80% vs period 2, 75,5%, p=0,63). The compliance for the methodology of blood culture obtainment was 2,2% in Period 1 and 25% in Period 2 (p<0,001). The empirical antibacterial treatment was concordant with guideline recommendations in 190 (83,7%) patients. The rate of compliance was 79,1% in Period 1 and 86,8% in Period 2 (p=0,13). The spectrum of the empirical antibacterial treatment was adequate in 58,3% of the patients with bacteremia in Period 1 while this rate was 88,1% in Period 2 (p=0,006). The need for escalation of antibacterial treatment was significantly lower in Period 2 (Period 1, 49,5% vs Period 2, 35,3%, p=0,03). The escalation was performed at median 3 (minimum 3- maximum 9) days in Period 1 while escalation was performed at median 4 (minimum 1- maximum 13) days in Period 2 (p=0,03). Fever response was obtained by the first-line empirical antibacterial treatment in 111 (48,9%) patients. This rate was 35,2% in Period 1 and 58,1% in Period 2 (p=0,001). The rate of 30-day mortality was 16,7% and there was no difference between two periods (p=0,78). This study showed that after the release of written guidelines, the efficacy of antibacterial treatment was increased. The increase in adequate spectrum of antibacterial treatment resulted with higher rate of fever response with the first-line empirical antibacterial treatment and the rate of escalation was decreased. The release of a written guideline improved the quality of empirical antibacterial treatment which was driven by the infectious diseases physicians, however, areas such as antimicrobial prophylaxis and use of GM antigen as a screening test as well as blood cultures still require certain improvement. Prospective interventional studies have a great potential to improve these areas, but these studies require time with high workload. Moreover, the sustainability of improvements achieved by clinical studies can be low particularly if the process can not be adapted to daily practice by an easy pathway. The use of clinical decision support systems integrated into the hospital information system to increase compliance with institutional guidelines can be an effective solution in terms of both providing regular feedback and facilitating access to necessary information.
