title: Implementation of risk stratified antibiotic therapy for neutropenic fever: what are the risks?
abstract: BACKGROUND
  A new national guideline for the management of febrile patients with severe neutropenia uses a risk stratification score to tailor treatment.
  
  
  OBJECTIVE
  To evaluate the implementation of this guideline in a metropolitan teaching hospital.
  
  
  METHODS
  A protocol was developed for implementation of the national guidelines for patients with neutropenic fever or at risk because of recent chemotherapy. Medical records of all patients presenting with fever to the haematology and oncology service for 3 months in 2011 were audited. Patients with a neutrophil count between 0.5 and 1.0 × 10(9) /L were classified as borderline neutropenia.
  
  
  RESULTS
  Eighty-one episodes of fever were treated on the protocol. Forty-three per cent of patients were neutropenic. Uptake of the policy was low (35%) despite concerted efforts. The sensitivity and specificity of the Multinational Association for Supportive Care in Cancer score was 86% and 24% respectively. The readmission rate with fever was 19.2%. Median time to antibiotics was 60 min. Outcomes were similar for the neutropenic fever and borderline groups. Increasing treatment complexity was the major barrier to implementation.
  
  
  CONCLUSIONS
  The majority of presentations with cancer and fever following chemotherapy do not have neutropenia but have similar outcomes when treated on the same pathway. The utility of the Multinational Association for Supportive Care in Cancer score was limited by uptake and specificity. Reducing time to antibiotics administration and readmission rates were identified as priorities. Implementation was labour-intensive and faced significant barriers. Prioritisation of evidence for translation requires attention to local priorities and implementation complexity. These results argue for a single sepsis guideline with treatment of cancer as a high-risk group.
authors.affiliation: Faculty of Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: Wierema
authors.forename: P
authors.initials: P
authors.lastname: Konecny
authors.forename: M
authors.initials: M
authors.lastname: Links
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D000970:Antineoplastic Agents / Q000009:adverse effects; D005260:Female; D005334:Fever / Q000139:chemically induced / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000379:methods*; D008875:Middle Aged; D009503:Neutropenia / Q000139:chemically induced / Q000188:drug therapy* / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D000970:Antineoplastic Agents
keywords: antibiotic; guideline; implementation science; neutropenic fever; quality improvement