2026 Southeastern Residency Conference

Inpatient Medication Use Evaluation of Chemotherapy-Induced Febrile Neutropenia

Background/Objective: Neutropenic fever occurs in about one percent of chemotherapy patients and requires prompt empiric antipseudomonal β‑lactam therapy. The Infectious Diseases Society of America (IDSA) guidelines recommend monotherapy with cefepime or piperacillin-tazobactam, as first-line empiric therapy. They do not recommend routine antiMethicillin-resistant Staphylococcus aureus (MRSA) coverage unless prior history of MRSA infection or differential diagnosis warrants coverage. In addition, the 2024 Working Group on Infections in Hematology and Oncology (AGIHO) guidelines now recommend discontinuing empiric antibiotic therapy after 72 hours of apyrexia regardless of absolute neutrophil count (ANC). The purpose of this study is to evaluate the appropriateness of antibiotic prescribing patterns for chemotherapy-induced febrile neutropenia (CIFN). The result will help develop a future project involving antimicrobial stewardship interventions with the goal of increasing guideline adherence.

Methods: This was a single-center retrospective cohort study. Patients at least 18 years of age admitted for CIFN between July 2023 to June 2025 at Atrium Health Navicent were identified through International Classification of Disease diagnosis codes. To be included in the study, patients were required to have ANC was less than 500 cells/µL following chemotherapy with a concurrent fever or a MASCC score less than 21 regardless of ANC and received intravenous antibiotics for greater than 72 hours. Patients who had nonchemotherapy induced neutropenic fever or documented allergies preventing guidelineadherent therapy were excluded from the study. The primary outcome was composite of appropriate empiric antibiotic therapy initiation and appropriate de-escalation of therapy after 72 hours. The secondary outcomes included appropriate empiric antibiotic initiation, appropriate de-escalation of empiric therapy at 72 hours, length of antibiotic therapy, microbiological culture results matched with appropriate de-escalation, mortality rate during hospitalization, and adverse events compared to appropriate therapy.

Results: A total of 95 patients were screened, and 42 were included in the study. The mean age was 56.2 years (IQR 49-64.5) with 50% being male. Antipseudomonal β-lactams were the most common empiric agents used with cefepime 71.4% (30/42) and piperacillintazobactam 23.8% (10/42) of cases, followed by vancomycin for MRSA coverage in 83.3% (35/42) of cases, and meropenem for Extended-spectrum beta-lactamase (ESBL) coverage in 2.4% (1/42) of cases. The primary composite outcome of appropriate empiric initiation and appropriate re-evaluation at 72 hours occurred in 19% of patients. The secondary outcomes of appropriate empiric initiation occurred in 31% of patients, and the rate of appropriate antimicrobial evaluation at 72 hours was 57.1% of patients. Culture-matched antibiotics were performed in 71.4% of patients. In-hospital mortality rate was 7.1% and adverse events rate was 2.4% in patients.

Conclusions: Most patients with chemotherapy‑induced febrile neutropenia received inappropriate empiric antibiotic initiation and inappropriate duration of antimicrobials per guideline recommendations. This quality improvement project identified several practice gaps and serves as a baseline for future projects involving antimicrobial stewardship at Atrium Health Navicent.