Introduction Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. Methods A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. Results Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. Conclusion Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

Background: Four-factor prothrombin complex concentrate (4FPCC) is used for emergent warfarin reversal, but dosing remains controversial. Following approval, further studies have evaluated a variety of fixed-dose regimens. The studies utilized lower doses as compared with package insert dosing and provided data in regard to efficacy, safety, and cost savings. Further data are needed, however, to determine which fixed-dose regimen provides optimal efficacy and safety for emergent warfarin reversal. Objectives: The purpose of this study is to evaluate the efficacy, safety, and cost-savings of a fixed-dose 4FPCC protocol. Methods: This multicentered, retrospective chart review of adult patients requiring 4FPCC for emergent warfarin reversal utilized a fixed-dose regimen of 1500 units. The 2 primary outcomes were the proportion of patients who achieved a post-4FPCC international normalized ratio (INR) of ≤1.5 and ≤2. Secondary outcomes included thrombotic events within 7 days of 4FPCC administration and survival to discharge. A cost analysis was also performed to identify potential cost savings. Results: Of the 64 patients included, 44 (68.8%) achieved a post-4FPCC INR ≤1.5, and 61 (95.3%) achieved a post-4FPCC INR ≤2.0. No thrombotic events were reported; 55 (85.9%) patients survived to hospital discharge. More than $1000 was saved per patient via utilization of the fixed-dose protocol. Conclusion and Relevance: A fixed-dose of 1500 units of 4FPCC successfully achieved a target INR of ≤1.5 in the majority of patients and resulted in no thrombotic events. This study adds to the data evaluating alternative 4FPCC dosing regimens in comparison to package insert recommended dosing.

infection who might not be tested elsewhere and link them to care. However, the utility of HIV testing in developing country EDs is not yet well established. Belize has the highest HIV prevalence in Central America yet its EDs do not routinely offer HIV testing. At the Karl Heusner Memorial Hospital Authority (KHMHA) Accident and Emergency Department (A&E) in Belize City, we assessed HIV testing need among the adult population based on prevalence of lack of prior HIV testing, reported risk of HIV infection, and interest in being tested in the ED. Methods: Between June and August of 2018, we recruited a random sample of KHMHA A&E patients and surveyed them using an audio computer-assisted selfinterviewer. Participants were English-speaking, 18-64 years old, not critically ill or injured, not a prison inmate/under arrest, and were able to provide informed consent. HIV positivity, prior testing prevalence, and reasons for no prior HIV testing were summarized. Reported HIV risk behaviors and HIV testing interest in the A&E were compared by prior HIV testing status. Multivariable logistic regression was used to identify factors associated with lack of previous HIV testing. Results: Of 301 KHMHA A&E patients screened for study eligibility, patientreported HIV prevalence was 6%. Of the 264 HIV-uninfected participants, 26% never had been tested for HIV. Of the 69 not previously HIV tested, 28% reported never having been offered testing. Of the 264 HIV-uninfected participants, 6.1% reported injection drug use and 49.2% report having condomless sex in the past 10 years. Prevalence of condomless sex with casual and exchange partners was similar for those never HIV tested vs. tested previously (casual: 25% vs. 27%, p<0.87; exchange: 7.4% vs. 9.7%, p<0.81). Belief in the importance of HIV testing for all A&E patients was similar for never HIV tested vs. tested previously (90% vs. 90%; p<0.30). Participants with fewer years of formal education (primary school or less as compared to tertiary education) (aOR: 4.75 [95% CI: 1.8, 12.4]) and males (aOR: 2.81 [95% CI: 1.5, 5.3]) were less likely to have been HIV tested (Table). Conclusion: Absence of prior HIV testing, lack of being offered an HIV test previously, and the high prevalence of reported HIV risk behaviors indicate that that patients in this developing country could benefit from an A&E-based HIV testing program. Furthermore, the overwhelming majority of patients are supportive of being tested for HIV in the A&E.