Clinical Pathway Encourages Adherence to National Guidelines for Febrile Neutropenia

Clinical pathways developed in accordance with national guidelines can improve adherence to recommendations regarding the use of empiric vancomycin in patients with febrile neutropenia (FN), according to a study published in the Journal of Oncology Pharmacy Practice.  
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FN is a common complication of myelosuppressive chemotherapy, occurring in 10-50% of patients with solid tumors and 80% of patients with hematologic malignancies. Currently, National Comprehensive Cancer Network (NCCN) guidelines recommend that FN be treated with antipseudomonal beta-lactam monotherapy. Those guidelines also state that empiric vancomycin should only be used in specific clinical circumstances, such as serious catheter-related infections or suspected pneumonia. However, studies have shown that physicians often deviate from these recommendations by using vancomycin when unnecessary, raising the concern for acquiring vancomycin resistance and placing patients at a greater risk for toxicity.  

To ensure clinicians adhere to current guidelines on when to initiate empiric vancomycin, a clinical pathway for FN was developed. In a study led by Mildred Vicente, Rush University Medical Center (Chicago, IL), researchers investigated the appropriateness of vancomycin prescribing based on consistency with guideline recommendations before and after implementation of a FN clinical pathway. They also evaluated whether there are identifiable risk factors associated with use of empiric vancomycin when not clinically indicated.

The analysis included 337 patients. A total of 206 patients were treated prior to implementation of the FN pathway, with 64% (n = 132) appropriately receiving vancomycin (n = 95) or antipseudomonal, beta-lactam monotherapy (n = 37) consistent with guideline recommendations. The remaining 74 patients (35.9%) received vancomycin without indication (n = 61) or did not receive it when it was indicated (n = 13).

A total of 131 patients received treatment after FN pathway implementation. Retrospective analysis revealed that 116 of these patients (88.5%) appropriately received vancomycin (n = 53) or antipseudomonal beta-lactam monotherapy (n = 63) consistent with guideline recommendations; 15 patients (11.4%) either received vancomycin without indication (n = 11) or did not receive vancomycin when they should have (n = 4).

Researchers found no link between patient comorbidities and inappropriate utilization of vancomycin for FN, nor
was a Hematopoietic Cell Transplantation Comorbidity Index score of ≥ 3 associated with inappropriate vancomycin prescribing.

“We found a significant increase in the rate of appropriate vancomycin use consistent with guidelines following the implementation of an FN clinical pathway at our hospital,” said the researchers. “Prior to the FN pathway, vancomycin use was inconsistent with the pathway in 35.9% of FN patients. Following the pathway, we found that inappropriate use of vancomycin occurred with only 11.4% of patients with FN.”

They concluded that pathways for FN could help providers achieve care more consistent with recommendations found in national guidelines, though more research on the potential factors associated with inappropriate vancomycin use is needed.—Sean McGuire 

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Vicente M, Al Nahedh M, Parsad S, Knoebel RW, Pisano J, Pettit NN. Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia [published online ahead of print September 8, 2016]. J Oncol
Pharm Pract. 
doi:10.1177/1078155216668672.