Antibiotic practice and stewardship in the management of neutropenic fever: a survey of US institutions.

OBJECTIVE: To describe neutropenic fever management practices among healthcare institutions. DESIGN: Survey. PARTICIPANTS: Members of the Society for Healthcare Epidemiology of America Research Network (SRN) representing healthcare institutions within the United States. METHODS: An electronic survey was distributed to SRN representatives, with questions pertaining to demographics, antimicrobial prophylaxis, supportive care, and neutropenic fever management. The survey was distributed from fall 2022 through spring 2023. RESULTS: 40 complete responses were recorded (54.8% response rate), with respondent institutions accounting for approximately 15.7% of 2021 US hematologic malignancy hospitalizations and 14.9% of 2020 US bone marrow transplantations. Most entities have institutional guidelines for neutropenic fever management (35, 87.5%) and prophylaxis (31, 77.5%), and first-line treatment included IV antipseudomonal antibiotics (35, 87.5% cephalosporin; 5, 12.5% penicillin; 0, 0% carbapenem).We observed significant heterogeneity in treatment course decisions, with roughly half (18, 45.0%) of respondents continuing antibiotics until neutrophil recovery, while the remainder having criteria for de-escalation prior to neutrophil recovery. Respondents were more willing to de-escalate prior to neutrophil recovery in patients with identified clinical (27, 67.5% with pneumonia) or microbiological (30, 75.0% with bacteremia) sources after dedicated treatment courses. CONCLUSIONS: We found substantial variation in the practice of de-escalation of empiric antibiotics relative to neutrophil recovery, highlighting a need for more robust evidence for and adoption of this practice. No respondents use carbapenems as first-line therapy, comparing favorably to prior survey studies conducted in other countries.

Penicillin allergy evaluation in hospitalized patients with hematologic malignancy.

A penicillin allergy testing service (PATS) assessed penicillin allergy in patients with hematologic malignancies; 17 patients who met criteria had negative skin testing. Patients who underwent penicillin challenge passed and were delabeled. Of delabeled patients, 87% received and tolerated ß-lactams during follow-up. Providers found the PATS valuable.

Standardized Discharge Planning Tool Leads to Earlier Discharges and Fewer Readmissions.

BACKGROUND: In an inpatient setting, aspects of discharge planning are often left to the provider's memory, leading to errors, inefficiencies, and avoidable costs. METHODS: A multidisciplinary team of oncology practitioners used process improvement methodologies to redesign the discharge planning process. INTERVENTIONS: The primary intervention was an evidence-based discharge planning tool, called the discharge navigator, used from admission through discharge. RESULTS: Thirty-day unplanned readmission rates decreased by 29.0% from preimplementation (March 2017 through August 2017) to postimplementation (September 2017 through March 2020). The percentage of patients discharged before noon increased 76.2%. A comparable service not utilizing the intervention saw lesser or no improvement in these measures. CONCLUSION: The tool provided a systematic approach to discharge planning. Key design elements included a centralized location within the electronic health record and an electronic shortcut to populate the tool. Although developed for a specialized population, most elements are applicable to any hospitalized patient.

Guideline implementation is effective at reducing proton pump inhibitor use in hematology-oncology units: A multidisciplinary intervention for reducing Clostridioides difficile risk.

We implemented a guideline for appropriate acid suppressant use in hematology-oncology patients. This intervention resulted in a sustained reduction in proton pump inhibitor (PPI) use without an increase in rates of gastrointestinal bleeding. Practice guidelines are effective in reducing PPI use, which is associated with risk of Clostridioides difficile infection.

Implementation of an Advanced Practice Provider Service on an Allogeneic Stem Cell Transplant Unit: Impact on Patient Outcomes.

Allogeneic stem cell transplantation (ASCT) is a complex medical procedure for some patients with hematologic malignancies. Most ASCTs occur at academic centers where either medical residents (house staff [HS]) or advanced practice providers (APPs) provide daily care. As a result of increasing work-hour regulations, APPs have assumed greater responsibilities, including those traditionally held by HS. In this study we evaluate ASCT patient outcomes by inpatient provider service. A retrospective, single-center chart review of ASCT patients was performed. ASCT patients admitted to an HS service from May 2011 to May 2012 (N = 86) were compared with ASCT patients admitted to a newly formed APP service from October 2012 to October 2013 (N = 81). As part of a secondary sensitivity analysis, we compared ASCT patients on the APP service to a subset of ASCT patients admitted to the HS service also from October 2012 to October 2013 (n = 27). Our primary outcomes were 100-day survival and relapse-free survival rates. Additional outcomes included length of stay (LOS), inpatient complications, and ordering behavior. Our primary pre- and post-analyses found no differences in 100-day overall survival and 100-day relapse-free survival rate between the services. The rate of pneumonia was lower on the APP service (15% versus 28%, P = .04), with no significant differences in other infectious complications. HS ordered more blood cultures (6.7 versus 4.2, P = .03) per patient than the APP service. There was no difference in LOS, readmission rates, or inpatient mortality. With regards to our secondary sensitivity analysis, no differences were found in 100-day overall survival and 100-day relapse-free survival rates between the services. There was a decreased LOS on the APP service (29.4 versus 37.2 days, P = .01). HS ordered more blood cultures (9.3 versus 4.2, P < .01) and more radiological films (8.1 versus 5.2, P = .05) per patient than the APP service. This increased ordering and LOS was associated with an increase in mean hospital charges on the HS service (P = .04). ASCT patients on an APP service had similar 100-day outcomes as those on the HS service. In the setting of limited resources, APPs are potential alternative providers for complex transplant inpatients.

Advancing LGBT Health at an Academic Medical Center: A Case Study.

Academic health centers are strategically positioned to impact the health of lesbian, gay, bisexual and transgender (LGBT) populations by advancing science, educating future generations of providers, and delivering integrated care that addresses the unique health needs of the LGBT community. This report describes the early experiences of the Penn Medicine Program for LGBT Health, highlighting the favorable environment that led to its creation, the mission and structure of the Program, strategic planning process used to set priorities and establish collaborations, and the reception and early successes of the Program.

The role of lapatinib in the preoperative therapy of breast cancer.

Preoperative or neoadjuvant chemotherapy is a well-established modality in the treatment of nonmetastatic breast cancer. Patients initially considered inoperable may be able to achieve operable status after preoperative chemotherapy and patients initially considered not to be candidates for breast conservation may convert to breast conservation status. Human epidermal growth factor receptor 2 (Her2)-positive tumors have been shown to have a more aggressive course including early local relapse and metastasis when compared to Her2-negative breast cancers, but the optimal use of Her2-targeted agents is constantly evolving as new agents become available. Preoperative studies allow us to quickly assess the activity of new agents and combinations for particular biological subsets of breast cancer.