A practical approach to febrile cancer patients: Diagnostic stewardship in Oncology units
Abstract
INTRODUCTION: Cancer and cytotoxic chemotherapy used for its treatment predispose to severe and often fatal infections. Prompt diagnosis and timely antibiotic therapy is crucial, with delays in initiating therapy having high mortality. Complete blood counts (CBC) are an inexpensive, standardized, preliminary investigation for management and follow-up of cancer patients with diagnostic and prognostic value.
METHOD: To study the types of infections associated with various cancers on chemotherapy, their etiologies and susceptibility patterns, and the hematological profile of these patients as predictors of infection.
RESULTS: A total of 21 patients (12 solid and 9 hematological malignancies) presented with 31 febrile episodes. WBC count (2079 cells/cu.mm), percentage of neutrophils (52.9%), absolute neutrophil (137.5 cells/cu.mm) and platelet counts (1,77,507 cells/cu.mm) were significantly lower in the 11 febrile neutropenic patients. Absolute lymphocyte count (412.7 cells/cu.mm) was reduced with strikingly lower NLR ratio (6.07) in neutropenic patients. Laboratory and radiological evidence were present in 14/15 episodes in hematological malignancies as compared to 10/16 episodes in solid malignancies (p value-0.0218). Unexplained clinical sepsis was common in solid malignancies (p-0.0202). Majority of documented infections were bacterial, caused by Gram negative bacilli, showing multi-drug resistance. Infectious etiologies were identified in 71.4% patients with febrile neutropenia >5days. Bacterial infections developed within 2 days of neutropenia, whereas viral infections and fungal infections manifested in prolonged neutropenia. Multi-site infections and higher mortality were seen in patients with febrile neutropenia. (p<0.04)
CONCLUSION: Febrile neutropenia is a common complication among patients on cancer chemotherapy with increased risk of morbidity and mortality. Early, rapid yet accurate diagnosis is key to prompt intervention. Hematological parameters such as TLC, platelet count, NLR and PLR are promising biomarkers in conjunction with morphological changes of neutrophils, thus proving CBC and peripheral smear to be simple, easily available, cost-effective and highly dependable screening tools especially in resource-poor settings.
README
GENERAL INFORMATION
- Title of Dataset: A practical approach to febrile cancer patients: Diagnostic stewardship in Oncology units
- Author Information:Authors: Sridevi H.B., Anisha Maria Fernandes, Sanyo D'souza, Prashantha B., Pooja Rao, Suchitra Shenoy M.
- Duration of data collection (single date, range, approximate date):12 months (Aug 2021- July 2022)
- Geographic location of data collection: Mangalore, Karnataka, India
- Information about funding sources that supported the collection of the data: Nil
SHARING/ACCESS INFORMATION
- Licenses/restrictions placed on the data: Nil
- Links to publications that cite or use the data: Nil
- Links to other publicly accessible locations of the data: Nil
- Links/relationships to ancillary data sets: Nil
- Was data derived from another source? no A. If yes, list source(s):
- Recommended citation for this dataset: H.B., Sridevi et al. (2024). A practical approach to febrile cancer patients: Diagnostic stewardship in Oncology units [Dataset]. Dryad. https://doi.org/10.5061/dryad.7sqv9s51w
DATA & FILE OVERVIEW
- File List: Dryad.xls
- Relationship between files, if important:
- Additional related data collected that was not included in the current data package:
- Are there multiple versions of the dataset? no
METHODOLOGICAL INFORMATION
In this prospective study over a 1-year period, all cancer patients admitted at two of our tertiary care centres, with signs and symptoms of infection were included. Patients on targeted therapies or immunomodulators, radiotherapy or post stem-cell transplant and immediate post-surgical (<30 days post-op) were excluded from the study.
The patients were monitored for markers of infection with CBC and C-reactive protein (CRP). Peripheral blood samples from cases were studied in the Coulter ® DXH800 haematology analyser (Beckman Coulter Inc., Miami, FL, USA). CBC parameters included haemoglobin (Hb), total leucocyte count (TLC), platelet count (PLT), differential leucocyte count (DLC). Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) were calculated using absolute neutrophil count, absolute lymphocyte count and platelet count. The peripheral smear stained with Leishman stain was studied for morphological assessment for any evidence of infections such as toxic change, toxic granules, presence of immature granulocytes, presence of any viral induced reactive lymphocytes, monocytosis, intracellular organisms and/or haemoparasites.
Microbiological investigations were based on clinical presentation. These included microscopy, culture, serological tests and molecular assays. Microscopy included Gram stain, Auramine-O stain and KOH mount. Culture was performed according to standard microbiology techniques for bacteria and fungi. Automated culture systems included BacT/ALERT system (BioMerieux, USA) for blood and sterile body fluids, and MGIT (BACTECTM) for suspected mycobacterial infections. Identification of the bacteria and yeasts, and antimicrobial susceptibility testing of the isolates was performed using the VITEK 2 Compact system (BioMerieux, France), and minimum inhibitory concentration (MIC) was interpreted using the Clinical and Laboratory Standards Institute (CLSI)12 guidelines. Serology and molecular tests were performed as per the clinician’s request.
Demographic and clinical data was extracted from the medical records including type of cancer, cancer treatment, clinical presentation, laboratory investigations, radiology findings, use of antibiotic/antifungal treatment and outcome. Episodes of Febrile Neutropenia (FN) were documented. The diagnosis of FN was made in the occurrence of a single oral temperature of ≥38.3°C (101°F) or 38.0°C (100.4°F) for more than 1 h along with an absolute neutrophil count (ANC) ≤500/µl or ≤1000/µl with predicted rapid decline during next 48hr8.
The collected data was entered into MS Excel, analysed and presented in the form of tables, pie charts and bar diagrams. A Mann-Whitney U test was used to assess the statistical differences between the two groups, and a Chi-square test was used to analyze the distribution of categorical variables. All data was analysed by JAMOVI software version 2.4.14. p value <0.05 will be taken as statistically significant.
Ethics and consent: Approval for this study was obtained from the Institutional Ethics Committee (Kasturba Medical College, Mangalore), Reg No. ECR/541/Inst/KA/2014/RR-20, DHR Reg. No. EC/NEW/INST/2020/742. The approval was given on 22.07.2021 with protocol number IEC KMC MLR-07/2021/230. The committee permitted a waiver of consent to participate from the patients as patient details and data were sourced from the case files and there is no direct contact between the researcher and participant.
DATA-SPECIFIC INFORMATION FOR: data_sheet.xlsx
- Number of variables: 35
- Number of cases/rows: 32
- Variable List:
| Variable C | Age range in years |
|---|---|
| Variable D | Gender M/F |
| Variable E | Type of cancer (Solid/hematological) |
| Variable F | System /organ of malignancy |
| Variable G | Haemoglobin |
| Variable H | Total Leucocyte Count |
| Variable I | Neutrophils |
| Variable J | Lymphocytes |
| Variable K | Eosinophils |
| Variable L | Monocytes |
| Variable M | Basophils |
| Variable N | Abnormal cells/Blasts |
| Variable O | Left shift Yes-Present, No-Absent |
| Variable P | Toxic changes Yes-Present, No-Absent |
| Variable Q | Absolute Neutrophil Count |
| Variable R | Absolute Lymphocyte Count |
| Variable S | NLR ratio |
| Variable T | Platelet count |
| Variable U | PLR ratio |
| Variable V | Microbiological evidence of infection Yes-Present, No-Absent |
| Variable W | Specimen - 1 for culture Type of specimen |
| Variable X | Organism-1 name |
| Variable Y | Organism-1Drug resistance pattern |
| Variable Z | Organism-2 name |
| Variable AA | Organism-2 Drug resistance pattern |
| Variable AB | Specimen - 2 for culture Type of specimen |
| Variable AC | Organism isolated Organism name |
| Variable AD | Drug resistance pattern |
| Variable AE | Other laboratory test evidence of infection Yes-Present, No-Absent |
| Variable AF | Radiological evidence of infection Yes-Present, No-Absent |
| Variable AG | Clinically defined infection Yes-Present, No-Absent |
| Variable AH | Patient outcome |