Antimicrobial de-escalation in patients with high-risk febrile neutropenia: Attitudes and practices of adult hospital care providers

Abstract

In a survey of adult hospital providers regarding antibiotic use in the treatment of febrile neutropenia, clinical fellows, and pharmacists showed higher comfort levels with early antimicrobial de-escalation compared to hematology-oncology and transplant infectious diseases physicians. These frontline team members are ideal partners to champion antimicrobial stewardship interventions in febrile neutropenia.

Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients

“…The educational effect of a case audit might be greater when performed face-to-face, as the positive effect of face-to-face communication on behavior is seen by others. 22 – 25 …”

Development and implementation of “handshake rounds”: An antibiotic stewardship intervention for hospitalized adult patients with hematologic malignancies

“…Antimicrobial stewardship interventions for special patient populations can be challenging to implement due to high levels of fear and anxiety among providers about patient outcomes. 10 Here, we describe the successful implementation of handshake rounds to change antibiotic prescribing habits for patients with hematologic malignancies. Although the initial intent of the intervention was to encourage early de-escalation of IV antibiotics in the management of febrile neutropenia, it was immediately apparent that those with ANC > 500 cells/µL were receiving more IV antibiotics than needed.…”

“…Thorough preintervention planning to understand the reasons why providers were hesitant to de-escalate IV antibiotics in this population led to a desire for handshake rounds. 10 Thoughtful development of this multidisciplinary approach strengthened the relationship between hematology–oncology providers, TID specialists, and pharmacists, and it laid a foundation of trust with mutual desire for good patient outcomes. Although not used for this study, use of a structured framework based on principles of behavior analysis, such as the behavior change wheel or the theoretical domains framework, 19 , 20 may aid in understanding barriers to behavioral change.…”

“…This team was selected because it includes hematology–oncology pharmacists and fellows; both were previously identified as more likely to feel comfortable with antimicrobial de-escalation. 10 In addition, it was determined that handshake rounds should be conducted between the hematology–oncology team pharmacist and a member of the ASP team who specialized in transplant–immunocompromised host infectious diseases (TID) to ensure proper fund of knowledge. Handshake rounds between the hematology–oncology team pharmacist and a TID physician were to be conducted 2–3 times per week over 16 weeks.…”

“…An algorithm for escalation of antimicrobials for the management of febrile neutropenia was widely used; however, guidance for de-escalation of IV antibiotics to oral prophylaxis released in January 2020 was not widely adopted. In a previously published study, 10 we reviewed findings of an internal survey of providers of high-risk febrile neutropenia patients to understand barriers to early antibiotic de-escalation in this setting. Using hypothetical clinical scenarios, we found that hematology–oncology fellows and hematology–oncology pharmacists were the groups most comfortable with early de-escalation practices.…”