Factors and Outcomes Related to the Use of Guideline-Recommended Antibiotics in Patients With Neutropenic Fever at the Uganda Cancer Institute

Abstract

Background Neutropenic fever (NF) is associated with significant morbidity and mortality for patients receiving cancer treatment in sub-Saharan Africa (sSA). However, the antibiotic management of NF in sSA has not been well described. We evaluated the timing and selection of antibiotics for patients with NF at the Uganda Cancer Institute (UCI). Methods We conducted a retrospective chart review of adults with acute leukemia admitted to UCI from January 1, 2016, to May 31, 2017, who developed NF. For each NF event, we evaluated the association of clinical presentation and demographics with antibiotic selection as well as time to both initial and guideline-recommended antibiotics. We also evaluated the association between ordered antibiotics and the in-hospital case fatality ratio (CFR). Results Forty-nine NF events occurred among 39 patients. The time to initial antibiotic order was <1 day. Guideline-recommended antibiotics were ordered for 37 (75%) NF events. The median time to guideline-recommended antibiotics was 3 days. Fever at admission, a documented physical examination, and abdominal abnormalities were associated with a shorter time to initial and guideline-recommended antibiotics. The in-hospital CFR was 43%. There was no difference in in-hospital mortality when guideline-recommended antibiotics were ordered as compared to when non-guideline or no antibiotics were ordered. (HR: 0.51, 95%CI: [0.10, 2.64] and 0.78, 95%CI: [0.20, 2.96], respectively). Conclusions Patients with acute leukemia and NF had delayed initiation of guideline-recommended antibiotics and a high CFR. Prospective studies are needed to determine optimal NF management in sSA, including choice of antibiotics and timing of antibiotic initiation.

How Should We Manage Antimicrobial Resistance in Resource-Limited Settings?

“…For example, we and our colleagues found that more than 50% of the bacteria isolated from Ugandan patients with neutropenic fever were resistant to the first-line antibiotics recommended in the US-based neutropenic fever guidelines. 9,10 As a result, the 30-day mortality rate for patients with neutropenic fever was 46% to 54%, 10,11 which contrasts starkly with the 2.6% to 21.4% mortality rate-depending on the number of comorbidities-for patients being treated in the United States. 12 As highlighted by our case, research studies may be one of the few avenues through which patients have access to affordable laboratory diagnostics.…”

Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study

“…Treatment guidelines have largely relied on evidence from high-income countries,3 unpublished data from treatment centres and anecdotal experience. The barriers to and facilitators of effective management which contribute to the high death rate of fevers in paediatric patients with cancer in SSA are currently unknown 9 18…”

Burden, risk factors, and management of neutropenic fever among solid cancer patients in Ethiopia

“…Empirical antibiotics therapy is standard practice in the treatment of NF. 9 , 10 However, there is a significant debate about the selection of initial antibiotic regimens. 3 The initial regimen in seriously ill patients should cover both gram-positive and gram-negative pathogens and should be administered intravenously.…”