Vicente, M., Al-Nahedh, M., Parsad, S., Knoebel, R.W., Pisano, J., & Pettit, N.N. (2017). Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia. Journal of Oncology Pharmacy Practice, 23, 575–581.

To determine the appropriateness of vancomycin prescribing, based on consistency with guideline (IDSA and NCCN) recommendations before and after implementation of FN clinical pathway. Secondary endpoint was to determine influence of comorbidities with inconsistent vancomycin use based on guideline recommendations.

Using IDSA and NCCN guidelines for prescribing vancomycin in adults patients with cancer with FN and a risk assessment tool for adverse clinical outcomes a pathway was developed to increase compliance with guidelines. 337 patient records were analyzed to evaluate effectiveness of FN clinical pathway at academic medical center. Patients admitted with FN and no allergy to beta-lactam were included. Four groups were evaluated: pre-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use inconsistent with guidelines and post-pathway vancomycin use inconsistent with guidelines. Vancomycin use was defined as use for at least 48 hours to exclude those receiving it for procedural prophylaxis.

• N = 337   
• AGE: Adults reported in mean and standard deviation for each group. Consistent vancomycin pre = 59 (SD = 13.3), consistent vancomycin post = 59.4 (SD = 15.6), inconsistent vancomycin pre = 55.5 (SD = 15.3), inconsistent vancomycin post = 51.3 (SD = 12.2)
• MALES: 59%  
• FEMALES: 41%
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Hematologic malignancy, solid tumor malignancy, stem cell transplantation autologous and stem cell transplantation allogeneic
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with diagnosis of neutropenia ICD 9 codes 288.00, 288.02, 288.03, 288.04, 299.08, and ICD 9 for fever. Adult FN patients who received an appropriate anti-pseudomonal beta-lactam with or without vancomycin were included in the analysis. Patients transferred from outside facility or with documented penicillin or vancomycin allergy were excluded.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: University of Chicago Medical Center

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care

Evaluate appropriate prescribing of vancomycin based on consistency with guideline recommendations pre- and post-implementation of a FN clinical pathway.

Antimicrobial usage report generated from electronic medical record. Hematopoietic Cell Transplantation Comorbidity Index (HCT CI)

The rate of vancomycin use, inconsistent with guideline recommendations in the pre-pathway implementation time frame, was significantly greater (n = 74, 35.9%) versus use in the post-pathway implementation time frame (n = 5, 11.4%; p = 0.001). No comorbidities or specific HCT CI scores were predictive of vancomycin without indication on multivariate analysis.

Implementation of a guideline-based pathway for FN in adult patients with cancer can significantly improve adherence to guideline recommendations for antimicrobial (vancomycin) use

• Findings not generalizable
• Other limitations/explanation: The use of HCT CI has not been validated in another malignancy except hematologic

Use of clinical pathways can improve compliance with guidelines for managing at-risk patients, leading to better outcomes.