A Quality Improvement Initiative to Optimize Fever and Neutropenia Management in Oncology Patients
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Published on: May 12, 2023
Maya Ilowite1,2, Mari M Nakamura2,3,4, Hanna Wardell2,3,4
1From the Division of Hematology/Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston, Mass.
Introduction:
Antibiotic durations in pediatric oncology inpatients with fever and neutropenia are often long, increasing the risk of adverse effects and selecting for antibiotic-resistant organisms. This quality improvement initiative aimed to decrease the monthly average empiric antibiotic duration for this population to 7 days or fewer.
Methods:
Historically, a major driver of prolonged empiric antibiotic durations was treatment until bone marrow recovery. However, literature suggests that antibiotics may safely be stopped sooner in the absence of a documented infection. We created a clinical pathway that recommended a defined empiric antibiotic duration of 7 days in clinically stable patients. Using the Model for Improvement, the pathway was implemented and revised based on feedback from clinicians. To assess the initiative's impact, we measured the monthly average inpatient empiric antibiotic duration for oncology patients with fever and neutropenia. As a balancing measure, we tracked the monthly percentage of patients who had a positive blood culture within 72 hours of discontinuing antibiotics. We used statistical process control charts to evaluate changes over time.
Results:
The mean monthly average duration of inpatient empiric antibiotics for our target population decreased to 5.0 days. The percentage of patients who had a positive blood culture within 72 hours of discontinuing antibiotics remained stably low.
Conclusions:
By implementing a clinical pathway that recommended a defined empiric antibiotic duration in stable patients, we successfully decreased antibiotic exposure for oncology patients with fever and neutropenia. We did not observe increased bacteremia events during the project period.
Insights
This quality improvement initiative successfully reduced empiric antibiotic durations for pediatric oncology inpatients with fever and neutropenia to 5 days. This was achieved without increasing the risk of bloodstream infections, demonstrating a safer approach to antibiotic use.
Area of Science:
- Pediatric Oncology
- Infectious Diseases
- Quality Improvement
Background:
- Prolonged antibiotic use in pediatric oncology patients with fever and neutropenia increases risks.
- Current practices often lead to extended antibiotic durations, contributing to antibiotic resistance.
Purpose of the Study:
- To decrease the monthly average empiric antibiotic duration for pediatric oncology inpatients with fever and neutropenia to 7 days or fewer.
- To implement and assess a clinical pathway for defined empiric antibiotic durations.
Main Methods:
- A quality improvement initiative utilized the Model for Improvement framework.
- A clinical pathway recommending 7 days of empiric antibiotics for stable patients was implemented.
- Statistical process control charts monitored antibiotic duration and bloodstream infection rates.
Main Results:
- The mean monthly average duration of inpatient empiric antibiotics decreased to 5.0 days.
- The percentage of patients with positive blood cultures within 72 hours of antibiotic discontinuation remained low.
- No increase in bacteremia events was observed during the project.
Conclusions:
- A clinical pathway effectively reduced empiric antibiotic exposure in pediatric oncology patients with fever and neutropenia.
- Defined antibiotic durations in stable patients are safe and do not increase bacteremia risk.
- This initiative supports optimizing antibiotic stewardship in pediatric oncology.
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