208 - Variation in Clinical Practice and Attitudes in the Management of Fever and Neutropenia in Patients With Hematologic Malignancy: A Survey of Cancer Centers Across the United States

Background: Fever and neutropenia (FN) is common in cancer patients after chemotherapy, and there are national guideline recommendations for FN prevention and treatment.  We conducted a survey of practices across multiple US cancer centers to determine the extent to which these guidelines have been adapted.

Methods: US cancer centers performing  20 allogeneic hematopoietic stem cell transplantations annually were identified from the National Marrow Donor Program’s “Be the Match” directory. Antimicrobial stewardship physicians and pharmacists at each institution were identified using institutional websites, residency or fellowship program directories, and personal contacts. A survey assessing institutional practices and individual attitudes on FN management in high-risk patients was distributed via email. Duplicate responses at the hospital level were removed.  Complete surveys regarding individual attitudes were assessed using a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.”

Results: Thirty-four (23%) responses from 148 individuals were received, representing 31 of 86 hospitals (36%). 29 (94%) hospitals reported having guidelines for the management of FN. Of these, cefepime was the most commonly recommended agent for empiric treatment (26, 90%) and 16 (55%) provide guidance based on presumed site of infection. Eighteen (62%) hospitals recommend de-escalation of Gram negative therapy in certain situations, most often after being afebrile 48 – 72 hours or after neutrophil recovery (7 each, 39%). Twenty-seven (93%) hospitals recommended antibiotic prophylaxis, most often with levofloxacin (21, 78%). Of 34 respondents, attitudes were split regarding the statement “The benefit of antibiotic prophylaxis outweighs the harms in high-risk patients” (10 strongly agree or agree, 10 strongly disagree or disagree; 29% each); most agreed with the statement “I would use antibiotic prophylaxis in high-risk patients” (25, 78%).

Conclusion: Most cancer centers across the US have guidelines for the management of FN. While most recommend antibacterial prophylaxis, there were differences in individual perceptions regarding the risk / benefit. Significant variation exists in the approach to antibiotic de-escalation.