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Implementation

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Implementation

"In the expanding group of patients with haematological, solid tumour malignancies or bone marrow transplant recipients, there is currently no standardised strategy for monitoring of infections, despite the fact that these patients have been identified as a nidus for threats from difficult-to-treat infections."

The objective of this stream is to implement a hospital-wide approach to recognition and management of febrile neutropenia (FN), invasive fungal infection and sepsis for patients being treated for cancer.

Programs

Cancer Sepsis Pathways

We have led a sepsis program for cancer patients across Western Central Melbourne Integrated Cancer Service (WCMICS) hospitals since 2012. It is currently in place as a whole-of hospital clinical pathway at Peter MacCallum Cancer Centre, in cancer services at St Vincent’s and Royal Melbourne and has been adapted for use at the Women’s (obstetrics) and Werribee Mercy (community) Hospitals.

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We have led a sepsis program for cancer patients across Western Central Melbourne Integrated Cancer Service (WCMICS) hospitals since 2012. It is currently in place as a whole-of hospital clinical pathway at Peter MacCallum Cancer Centre, in cancer services at St Vincent’s and Royal Melbourne and has been adapted for use at the Women’s (obstetrics) and Werribee Mercy (community) Hospitals.

Low risk febrile neutropenia program

Febrile neutropenia is the most common complication of the treatment of cancer and the leading cause of unplanned hospital admissions, with over 2600 adult admissions in Victoria in 2008 and 180 paediatric admissions in 2014. FN is defined as the development of fever, often with other signs of infection, in a patient with neutropenia, an abnormally low number of neutrophil granulocytes  in the blood.

The current standard of treatment for febrile neutropenia is admission of all patients, irrespective of the underlying risk, for intravenous antibiotics until fever is resolved and neutrophil count recovers. This approach over-treats up to 50% of patients. National and international guidelines support the safe management of patients deemed low-risk for medical complications outside of the inpatient setting. On a background of increasing demand for cancer services as the population ages, implementation of outpatient management for febrile neutropenia allows patients to be managed more comfortably at home with resultant increase in access to inpatient beds and associated indirect cost savings to manage other more seriously unwell patients.

This program is responsible for the identification and management of low-risk febrile neutropenia patients in an outpatient setting.  Possible outcomes include: improved patient quality of life through outpatient versus inpatient management, a reduction in the patients’ risk of hospital acquired infections by minimising interventions, increased bed capacity from early hospital discharge of low-risk FN patients, reduced hospital length of stay for patients with FN resulting in indirect cost benefits from improved bed turnover, and utilization and development of specialist staff for consistency and quality of cancer care.

Electronic Fungal Management system

Invasive fungal disease (IFD) is a lethal and costly complication of modern cancer treatments and occurs in up to 30% of acute leukemia and 10% of stem cell transplant recipients. Mortality is 50-68% (1) and delays in treatment increase mortality (2, 3). Further, these infections impact on cancer-specific treatments resulting in delayed delivery and poorer outcomes (4). Notably we have shown in the Australian health care setting IFD’s result in a mean excess cost of $79,000 and length of hospital stay of 15 days (5). If ICU admission was required costs doubled (5). Antifungal drugs are in the top 10 pharmacy budget items for haematology patients. Despite these alarming metrics, interventions such as introduction of rapid diagnostic tests are lacking. Surveillance is rarely performed as it is costly, time consuming and not sustainable (6, 7). Building on an existing antimicrobial stewardship platform, Guidance MS (successfully implemented in 62 hospitals Australia-wide) and a prototype text-mining module we have developed a real-time electronic fungal management system providing a single data source relating to fungal infection history, risk and guidelines as well as collecting data. In conjunction with the National Centre for Antimicrobial Stewardship we will also develop metrics and approaches for antifungal stewardship in transplant recipients.  The role of diagnostics and TDM in stewardship will also be evaluated. 

1. Thursky et al., Bone Marrow Transplant, 2004, 2. Slavin et al., J Antimicrob Chemother, 2010, 3. Marr et al., Ann Intern Med, 2015, 4. Even et al., Haematologica, 2011, 5. Ananda-Rajah et al., Antimicrob Agents Chemother, 2011, 6. Ananda-Rajah et al.,PLoS One ,2014 and 7.Ananda-Rajah et al., Curr Opin Infect Dis, 2012.

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