Suresh babu, M C (2011) Performance of Multinational Association of Supportive Care of Cancer (MASCC) Risk Index Score for Identifying Low Risk Adult Febrile Neutropenic Cancer patients. Masters thesis, Cancer Institute (W.I.A), Adyar , Chennai.
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Abstract
Introduction: Febrile neutropenia (FN) represents one of the most common complications Of chemotherapy in cancer patients1. Chemotherapy induced neutropenia remains a Life threatening complication despite progress in our understanding and in the Treatment of this event. Now days the accepted standard of care for such patients Has been administration of empiric, broad spectrum antibiotics, and close monitoring For development of complications until fever resolution and neutropenia recovery. Though treatment of such patients can be done as in-patients in hospitals, not all Febrile neutropenia patients require intensive treatment2. Many investigations have indicated that neutropenic patients with fever are a Heterogeneous population, with subsets with varying risks regarding response to Initial therapy, development of serious medical complications, and mortality. Over the Past decade, several investigators have identified subsets of febrile neutropenic Patients who are at low risk for the development of complications, including mortality. Several clinical studies involving neutropenic patients with predicted low risk have Demonstrated the feasibility of newer approaches, such as outpatient therapy after Early discharge from the hospital or outpatient therapy for the entire febrile episode, Using parenteral, sequential (intravenous [IV] followed by oral), or oral antibiotic Regimens3. Febrile Neutropenia can be defined as a single oral temperature ≥ 38.3°C or 101°F or a temperature of ≥ 38°C or 100.4°F for at least 1 hour 5. , With absolute Neutrophil count (ANC) < 500 cells/mm3 or an ANC < 1,000 cells/mm3 with a Predicted decline to < 500 cells/mm3. At least one-half of febrile neutropenic patients have a documented or occult Infection. At least one-fifth of patients with neutrophil counts < 100 cells/mm3 have Bacteremia. Fungi can be causes of secondary infection in neutropenic patients who Have received broad-spectrum antibiotics and may also cause primary infections. The primary anatomic site of infection is the gastrointestinal tract, where mucosal Damage from chemotherapy allows invasion of micro-organisms. Damage to the skin From invasive procedures, such as intravascular devices, similarly provides portals of Entry for microbes. The duration of neutropenia is also an important determinant of risk of Infection. Patients with a low ANC and prolonged neutropenia (eg, > 10 days) are at Further increased risk of infection 7. Risk assessment is important in deciding whether febrile neutopenic patients Can be treated as inpatients or outpatients and whether oral or intravenous Antibiotics can be used. Historically, characteristics of low risk for serious medical Complications include outpatient conventional chemotherapy for solid tumors, normal Chest x-ray, hemodynamic stability, expected duration of neutropenia ≤ 7 days, Normal kidney and liver function tests, early evidence of marrow recovery, Malignancy in remission, and normal mental status. Management of patients with febrile neutropenic fever is complex and Involves careful consideration of multiple factors. At least one-half of neutropenic Patients who become febrile have a documented or occult infection. The Microbiology of infections has shifted, with more gram-positive infections, increased Drug resistance, and previously less common organisms being seen more frequently. Risk assessment is needed to determine whether inpatient or outpatient treatment is Indicated and whether intravenous or oral antibiotics can be used 7. A thorough history is extremely important when evaluating patients for febrile Neutropenia. The history should include the nature of the chemotherapy given, prior Antibiotic prophylaxis, concomitant steroids or other immunosuppressive’s, recent Documented colonization or infection with susceptibilities, recent surgical Procedures, and medication allergies. In neutropenic patients, symptoms and signs of inflammation may be minimal Or absent. The lack of inflammatory response can make detection of infection more Difficult and requires close physical examination for more subtle signs and Symptoms. There will likely be decreased erythema, induration, and purulence in Response to bacterial infections (eg, a skin infection without typical features of Cellulitis, a pulmonary infection without a clear infiltrate, meningitis that lacks Cerebrospinal fluid pleocytosis, and urinary tract infections without pyuria). Careful Evaluation of common sites of infections should include the mouth, pharynx, Esophagus, lungs, perineum, eyes, skin, and vascular catheter access sites. Laboratory studies include measurement of complete blood counts, serum Creatinine levels, blood urea nitrogen, transaminase levels, and blood cultures. Blood Cultures should be obtained from a peripheral vein and catheter if present. Depending on the clinical situation, other cultures can be obtained. Skin biopsies can Also be obtained if indicated. If respiratory signs or symptoms are present, a chest xray Can be performed6. There is a growing interest in designing risk-adapted strategies for the Management of FN. The administration of parenteral, broad-spectrum empirical Antibiotic therapy after the hospitalisation of patients with FN is the accepted Standard of care. This approach is effective (with an infection-related mortality rate of less than 10%) but is expensive and, when applied to all patients with FN, may represent a Suboptimal use of resources. Over the past decade, the development of risk Stratification models has allowed for the identification of low-risk patients with Additional treatment strategies, such as initial hospitalisation followed by early Discharge with parenteral or oral antibiotics (sequential therapy) and out-patient Treatment with oral antimicrobials. The most attractive option is out-patient treatment for the entire febrile Episode, because of several advantages, including important repercussions on Economic costs and quality of life as well as significant reduction in nosocomial Super infections. Careful selection of patients at a low risk of developing Complications, appropriate empirical regimens and the daily monitoring of patients (for response and toxicity) are critical for the success of this approach. Expected Duration of neutropenia (less than 10 days and under 60 years of age) and Favourable social and economic environment, with access to prompt medical Attention, are relevant prerequisites for considering this approach 11 . Epidemiology of infection is influenced not only by the severity and duration of Neutropenia, but also by the intensity of chemotherapy, the use of prophylaxis and/or Empirical antibiotic therapy, the use of central venous catheters, environmental Factors and duration of the hospital stay, among others. The detection of epidemiological shifts requires frequent monitoring and Surveillance, particularly at centres treating large numbers of patients, as institutional Differences can be substantial. For example, in recent years, some hospitals have Experienced an increase of infections caused by multidrug-resistant gram-negative Bacilli, such as Acinetobacter species or Stenotrophomonas maltophilia, and grampositive Cocci with increasing resistance to glycopeptides.Many reports have Demonstrated the emergence gram-positive organisms in patients with neutropenia. The practice of antimicrobial prophylaxis has been questioned repeatedly. Although oral prophylaxis against bacterial and fungal infections may decrease the Risk of development of infections after bone marrow transplantation or chemotherapy, These practices also promote the emergence of drug-resistant strains (particularly Fluoroquinolone-resistant Escherichia coli and fluconazole-resistant non-albicans Candida species). The use of fluoroquinolones for prophylaxis in high-risk patients With neutropenia has been also associated with the emergence of resistance among Pseudomonas aeruginosa isolates (more than 20% at some institutions). The 2002 Guidelines from the Infectious Diseases Society of America (IDSA) did not Recommend the routine fluoroquinolone prophylaxis during neutropenia. However, This may be considered for high-risk patients in critical periods of time 11. Several predictive models have indeed been developed to identify patients at Low risk of complications. Two classification systems are notable, Talcott Classification of risk groups and a scoring system proposed by the Multinational Association for Supportive Care in Cancer (MASCC) group. Both systems use Serious medical complications as the endpoint for risk prediction. However, the Sensitivity of the Talcott classification is limited (approximately 30%), and the Misclassification rate is high. For example, many patients who do not have Complications are not identified by the prediction rule. Also, when the classification System was used on patients discharged for home intravenous antibiotics after 2 Days of inpatient observation, the complication rate was higher than anticipated, The So-called Multinational Association for Supportive Care in Cancer (MASCC) scoring System has been internationally validated under various clinical conditions and has Been widely accepted. The use of the MASCC score also allows the selection of lowrisk Patients who can be safely treated with orally administered antibiotics and be, for At least some of them, successfully discharged early after a 24-h in-hospital Observation1,3. Febrile neutropenic cancer patients will have different risk of developing a Serious infection related complications. Although, there are no universally accepted Criteria to recognise these patients, currently the most used model of prediction of Complications is the multinational association of supportive care (MASCC) index Score2. This study was designed to validate MASCC index score in an attempt to Accurately predict, on presentation with febrile neutropenia, which cancer patients Are at low or high risk of developing serious medical complications during the Episode. Aims And Objectives: The primary objective of this study was to validate the performance of the Multinational Association for Supportive Care in Cancer (MASCC) risk index, in Predicting the outcome of febrile neutropenia in adult cancer patients in the local Health care setting of Cancer institute ,chennai. The secondary objectives included the evaluation of the clinical outcome, Infective aetiology and prognostic factors of febrile neutropenia in the local Population.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Multinational Association Supportive Care Cancer ; Risk Index Score ; Low Risk ; Adult Febrile Neutropenic ; Cancer patients. |
| Subjects: | MEDICAL > Medical Oncology |
| Depositing User: | Subramani R |
| Date Deposited: | 19 Aug 2017 03:35 |
| Last Modified: | 19 Aug 2017 03:35 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/2034 |
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