Febrile neutropenia in French emergency departments: results of a prospective multicentre survey.
BACKGROUND
Febrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).


METHODS
This prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.


RESULTS
198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).


CONCLUSIONS
In this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.
André
Stéphanie
S
Department of Emergency Medicine, Hôpital Cochin, APHP, rue du Faubourg Saint-Jacques, Paris Cedex 14, France. stephanie.andre@cch.aphp.fr
Taboulet
Pierre
P
Elie
Caroline
C
Milpied
Noël
N
Nahon
Michel
M
Kierzek
Gérald
G
Billemont
Mariève
M
Perruche
Franck
F
Charpentier
Sandrine
S
Clément
Hélène
H
Pourriat
Jean-Louis
JL
Claessens
Yann-Erick
YE
D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000188:drug therapy*; D005602:France; D019538:Health Care Surveys; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000188:drug therapy; D009503:Neutropenia / Q000175:diagnosis / Q000188:drug therapy*; D019370:Observation; D011446:Prospective Studies; D012720:Severity of Illness Index
D000890:Anti-Infective Agents; D000970:Antineoplastic Agents
Clin Infect Dis. 2002 Mar 15;34(6):730-51
11850858
Curr Opin Infect Dis. 2001 Aug;14(4):415-22
11964858
Crit Care Med. 2003 Mar;31(3):670-5
12626967
Clin Infect Dis. 1999 Aug;29(2):463-4
10476774
Clin Oncol (R Coll Radiol). 2001;13(3):204-8
11527297
J Clin Oncol. 2000 Aug;18(16):3038-51
10944139
Nurs Clin North Am. 2001 Dec;36(4):631-44, v
11726344
Med Clin North Am. 1971 May;55(3):729-45
4325096
Ann Emerg Med. 2006 Sep;48(3):326-31, 331.e1-3
16934654
J Infect. 2009 Nov;59(5):332-6
19706307
Presse Med. 2004 Mar 13;33(5):324-6
15041883
Crit Care Med. 2007 Nov;35(11):2525-32
18075366
Crit Care Med. 2001 Jul;29(7):1303-10
11445675
Am J Emerg Med. 1992 Nov;10(6):538-41
1388378
Clinics (Sao Paulo). 2008 Aug;63(4):457-64
18719755
Clin Infect Dis. 1999 Sep;29(3):515-21
10530438
J Chronic Dis. 1987;40(5):373-83
3558716
Clin Infect Dis. 2005 Nov 15;41 Suppl 7:S481-9
16237651
Intensive Care Med. 2002 Feb;28(2):108-21
11907653
Intensive Care Med. 2003 Apr;29(4):530-8
12664219
Shock. 2009 Jul;32(1):35-9
19533847
Br J Cancer. 2003 Aug 18;89(4):641-7
12915871
Crit Care Med. 2006 Jun;34(6):1589-96
16625125
JAMA. 2008 May 21;299(19):2294-303
18492971
Ann Intern Med. 1991 Feb 15;114(4):332-3
1987879
Crit Care Med. 2004 Mar;32(3):858-73
15090974
Oncol Nurs Forum. 2001 Mar;28(2 Suppl):11-6
11291207
Crit Care Med. 2007 Aug;35(8):1928-36
17581480
Crit Care. 2003 Jun;7(3):R24-34
12793887
Ann Fr Anesth Reanim. 2007 Jan;26(1):53-73
17174063
J Clin Oncol. 2009 Dec 10;27(35):6052-69
19901123
Eur J Cancer. 2006 Oct;42(15):2433-53
16750358