Variation in Antibiotic Prescription in High-Risk Febrile Neutropenia in Portuguese Hospitals
Abstract
:1. Introduction
2. Results
3. Discussion
4. Materials and Methods
4.1. Study Design and Participants
4.2. Data Collection
- Name of participating hospital and corresponding Regional Health Administration;
- Type of facility (department or unit);
- Size of the respective department or unit, regarding the number of beds and the number of attending physicians;
- Department or unit experience in high-risk FN estimated first by the quantity of FN episodes treated on the ward per month and second by their differentiation in induction chemotherapy for AML or autologous or allogeneic bone marrow transplantation;
- The availability of an internal protocol for antibiotic therapy in high-risk FN;
- Description of the usual decision-making context regarding antibiotic therapy in high-risk FN (discussion in a department or unit meeting, discussion with colleagues our individual decision-making);
- Individual experience of the attending physician, inferred from questions regarding the level of training (specialist or resident); the number of years as a specialist (<5 years or ≥5 years); and the number of high-risk FN treated per month under direct care responsibility.
- Clinical vignette 1 illustrated a scenario where an “escalation strategy” starting with narrower-spectrum therapy would be recommended by most guidelines. Respondents were presented with options representing both narrower-spectrum (escalation strategy) and broader-spectrum (de-escalation strategy) choices, which were categorized accordingly;
- In clinical vignette 2 responders could opt between an antibiotic-sparing short-course treatment, irrespective of ANC, supported by ECIL-4 and NICE guidelines, and two other regimens: a treatment duration of at least 7 days, commonly used in clinical practice, or treatment until ANC ≥ 500 cells/μL, supported by IDSA guidelines;
- Clinical vignette 3 depicts a situation where de-escalation would be appropriate according to most guidelines. Respondents could opt to de-escalate based on culture isolation and AST, solely modify the regimen by discontinuing broader spectrum antibiotics, or maintain the broad-spectrum empiric regimen.
4.3. Data Analysis
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Guideline | Empirical Antibiotic Therapy for Patients without Risk Factors for MDR Infections, Complicated Presentation, Clinical Instability, or Sepsis | Discontinuation of Antibiotic Therapy Dependent on Absolute Neutrophil Count (ANC)? | Minimal Duration of Antimicrobial Therapy | Microbiologically Directed De-Escalation |
---|---|---|---|---|
NICE | Escalation approach | No | Discontinuation when neutropenic sepsis has responded to treatment. | Yes |
ECIL-4 | Escalation approach | No | 3 days if the patient has been afebrile and clinically stable for ≥48 h. | Yes |
ESMO | Escalation approach | No | 5–7 days if afebrile and symptom free. Except in high-risk cases where antibiotics are continued for 10 days or until ANC recovery. | Yes |
AGIHO | Escalation approach | No | 7 days after resolution of fever | Yes |
IDSA | Escalation approach | Yes | Dependent on ANC recovery (≥500 cells/μL) | Yes |
n | % | |
---|---|---|
Professional Experience | ||
Resident | 11 | 35.5 |
Specialist < 5 years | 5 | 16.1 |
Specialist ≥ 5 years | 15 | 48.4 |
FN assisted */month | ||
0–1 | 5 | 16.1 |
2–5 | 8 | 25.8 |
6–10 | 4 | 12.9 |
11–20 | 7 | 22.6 |
>20 | 7 | 22.6 |
Decision Making | ||
Individually made by assistant doctor | 12 | 38.7 |
Discussed with hematology colleague | 8 | 25.8 |
Department Meeting | 11 | 35.5 |
n | % | |
---|---|---|
No. Beds | ||
variable, allocated to other departments | 7 | 38.9 |
>20 | 11 | 61.1 |
No. Physicians | ||
<5 | 7 | 38.9 |
>10 | 11 | 61.1 |
AML Inpatient Care | ||
no | 2 | 11.1 |
yes | 16 | 88.9 |
Autologous BM Transplant | ||
no | 7 | 38.9 |
yes | 11 | 61.1 |
Allogenic BM Transplant | ||
no | 9 | 50 |
yes | 9 | 50 |
Characteristics of Clinical Hematologists | Characteristics of Hematology Departments | ||||||
---|---|---|---|---|---|---|---|
Length of Antibiotic Therapy | Short treatment Irrespective of ANC | Long treatment: 7-day length or Until ANC ≥ 500 cells/μL | Short treatment Irrespective of ANC | Long treatment: 7-day length or Until ANC ≥ 500 cells/μL | |||
Professional Experience | Department Size | ||||||
Resident | 18.2% (2) | 81.8% (9) | Large | 36.4% (4) | 63.6% (7) | ||
Specialist < 5 years | 20% (1) | 80% (4) | Small | 28.6% (2) | 71.4% (5) | ||
Specialist ≥ 5 years | 26.7% (4) | 73.3% (11) | |||||
FN Assisted/Month | High-Risk FN Protocol | ||||||
<2 | 20% (1) | 80% (4) | No | 20% (1) | 80% (4) | ||
2–10 | 16.7% (2) | 83.3% (10) | Yes | 38.5% (5) | 61.5% (8) | ||
>10 | 28.6% (4) | 71.4% (10) | |||||
Decision Making | Hospitals Performing ChT for AML/ Hospitals Performing BMT | ||||||
Individually made by assistant doctor | 16.7% (2) | 83.3% (10) | Yes/Yes | 36.4% (4) | 63.6% (7) | ||
Discussed with hematology colleague | 25% (2) | 75% (6) | Yes/No | 20% (1) | 80% (4) | ||
Department Meeting | 27.3% (3) | 72.7% (8) | No/No | 50% (1) | 50% (1) | ||
Total | 22.6% (7) | 77.4% (24) | 33.3% (6) | 66.7% (12) |
Characteristics of Clinical Hematologists | Characteristics of Hematology Departments | ||||||
---|---|---|---|---|---|---|---|
De-escalation According to AST | AST-guided de-escalation | Non de-escalation despite AST | AST-guided de-escalation | Non de-escalation despite AST | |||
Professional Experience | Department Size | ||||||
Resident | 36.4% (4) | 63.6% (7) | Large | 36.4% (4) | 63.6% (7) | ||
Specialist < 5 years | 80% (4) | 20% (1) | Small | 57.1% (4) | 42.9% (3) | ||
Specialist ≥ 5 years | 20% (3) | 80% (12) | |||||
FN Assisted/Month | High-Risk FN Protocol | ||||||
<2 | 60% (3) | 40% (2) | No | 40% (2) | 60% (3) | ||
2–10 | 33.3% (4) | 66.7% (8) | Yes | 46.2% (6) | 53.8% (7) | ||
>10 | 28.6% (4) | 71.4% (10) | |||||
Decision Making | Hospitals Performing ChT for AML/ Hospitals Performing BMT | ||||||
Individually made by assistant doctor | 41.7% (5) | 58.3% (7) | Yes/Yes | 36.4% (4) | 63.6% (7) | ||
Discussed with hematology colleague | 37.5% (3) | 62.5% (5) | Yes/No | 40% (2) | 60% (3) | ||
Department meeting | 27.3% (3) | 72.7% (8) | No/No | 100% (2) | 0 | ||
Total | 35.5% (11) | 64.5% (20) | 44.4% (8) | 55.6% (10) |
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Freitas, M.; Andrade, P.; Pinto, R.; Trigo, F.; Azevedo, A.; Almeida, F. Variation in Antibiotic Prescription in High-Risk Febrile Neutropenia in Portuguese Hospitals. Antibiotics 2024, 13, 822. https://doi.org/10.3390/antibiotics13090822
Freitas M, Andrade P, Pinto R, Trigo F, Azevedo A, Almeida F. Variation in Antibiotic Prescription in High-Risk Febrile Neutropenia in Portuguese Hospitals. Antibiotics. 2024; 13(9):822. https://doi.org/10.3390/antibiotics13090822
Chicago/Turabian StyleFreitas, Marta, Paulo Andrade, Ricardo Pinto, Fernanda Trigo, Ana Azevedo, and Francisco Almeida. 2024. "Variation in Antibiotic Prescription in High-Risk Febrile Neutropenia in Portuguese Hospitals" Antibiotics 13, no. 9: 822. https://doi.org/10.3390/antibiotics13090822