Impact of Computerized Decision Support for ANTIBIOtic Prescription in Cancer Patients With Febrile NEutropenia in the Emergency Department on Treatment Failure.

Study Overview
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Brief Summary
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Treatment of patients with febrile neutropenia (FN) attending Emergency Departments (EDs) relies on rapid antibiotic initiation in order to control a presumed infection. The choice of initial antibiotics is empirical and depends on patient's prior colonization or infection by multi-drug resistant pathogens (MDRPs) and risk stratification. Stratification of high-risk patients needing broad-spectrum antibiotics is debated. Thus, for non-specialist physicians, this choice may be challenging, leading to inappropriate initial antimicrobial regimens, potential risks for the patient and higher costs. Furthermore, international guidelines recommended to develop antibiotic stewardship programs and promoted an initial strategy based on escalation or de-escalation approaches, with early reassessment depending on patients' clinical course and microbiological results. Nevertheless, this interesting strategy may increase the level of complexity for the choice of the initial antibiotic regimen by non-specialist emergency physicians who are often the first prescribers in this context. We developed an interactive computerized decision support app (CDSA) for initial antibiotic prescription and early revaluation in patients with FN. The first goal of this app is to assist non-specialized physicians in choosing initial antimicrobial regimen for patients with FN when they attend EDs. It uses an interactive algorithm based on international guidelines that takes into account patients' medical history and characteristics. Secondly, the app is also designed to propose an algorithm of antibiotic revaluation at day 3-4 for hospitalized patients, depending on patient clinical course, and biological and microbiological results. The revaluation suggests antimicrobial modification (escalation or de-escalation) or discontinuation and stopping rules with recommended duration of therapy also based on international guidelines. We hypothesize that such a CDSA may improve the adherence to guidelines for the choice of initial antibiotic regimen for FN in the ED, favour early antibiotic reassessment for hospitalized patients, both decreasing the risk of treatment failure.

Official Title
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Impact of Computerized Decision Support for ANTIBIOtic Prescription in Cancer Patients With Febrile NEutropenia in the Emergency Department on Treatment Failure. A Randomized Cluster-controlled Trial.

Conditions
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Febrile Neutropenia

Intervention / Treatment
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* Other: routine care
* Other: Computerized Decision support app (CDSA)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: age ≥ 18 years; reported or observed fever at arrival at the ED (≥38.3° C on one occasion or ≥38°C on two or more occasions within 1 h); chemotherapy-induced neutropenia (absolute neutrophil count ≤500/mm3 or ≤1000/mm3 and anticipated to decrease to fewer than 500/mm3 within 24 to 48 h). Exclusion Criteria: refusal to participate; prior inclusion in the study for a previous episode of FN; any intravenous antibiotic administration during the preceding 72 h; renal failure requiring renal replacement therapy or with an estimated creatinine clearance of less than 20 ml/min; palliative status with life expectancy of less than three days; pregnancy, absence of health insurance, mental deficiency or inability to understand informed consent, no French speaking; patient with a microbiological documented infection when arriving at the ED (e.g. positive blood culture).

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: Stepped wedged design
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Control Group<br>As routine care, the choice of the initial antibiotic regimen will be let to the discretion of the emergency physician. | Other: routine care<br>* The choice of the initial antibiotic regimen will be let to the discretion of the emergency physician<br>|
| Experimental: computerized decision support app (CDSA) Group<br> | Other: Computerized Decision support app (CDSA)<br>* Implementation of an Computerized Decision support app (CDSA) : physician will use this app to help him in the antibiotic choice. This app is an interactive algorithm based on international guidelines that takes into account patients' medical history and characteristics. Secondly, the application is also designed to propose an algorithm of antibiotic revaluation at day 3 for hospitalized patients, depending on patient clinical course, and biological and microbiological results. The revaluation suggests antimicrobial modification (escalation or de-escalation) or discontinuation and stopping rules with recommended duration of therapy also based on international guidelines.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment failure | Treatment failure will be defined by any escalation of the assigned empirical initial antibiotic treatment (e.g. adjunction of aminoglycoside, glycopeptide or other anti-gram positive or any broadening of the beta-lactam spectrum) during the 7 days following inclusion, in relation with at least one of the following reasons: microbiologic reason; clinical progression of the presumed infection defined as persistence, recurrence or worsening of clinical signs or symptoms of presenting infection (e.g. death due to the initial infection, occurrence of sepsis or septic shock, need for oxygen therapy (or increasing oxygen flow) or mechanical or non-invasive ventilation in case of pneumonia, neurological deterioration in case of central nervous system infection). Treatment failure outcome will be reviewed by at least 2 experts blinded to the arm. | 7 days following inclusion | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of initial antibiotic regimen adhering to the international guidelines |  | at inclusion | 
| Time to antibiotic initiation from patient triage at the emergency department (minutes) |  | at inclusion | 
| Number of revaluations of initial antibiotic regimen at day 3 depending on patient clinical course and microbiological results; |  | at 3 days | 
| Number of antimicrobial spectrum reductions |  | at 3 days | 
| Number of antibiotic regimens with carbapenems, aminoglycosides or glycopeptides |  | at inclusion | 
| Number of days of Carbapenems, aminoglycosides and glycopeptides therapy |  | up to 3 months | 
| Number of super-infections | A super-infection will be defined as new, persistent or worsening symptoms and/or signs of infection associated with the isolation of a new pathogen (different, or different susceptibilities) or the development of a new site of infection; | up to 3 months | 
| Number of super-infections due to clostridium difficile |  | up to 3 months | 
| Number of colonization | Colonization will be defined as isolation during or after therapy of Gram-negative bacteria resistant to the beta-lactam included in the empirical regimen, without symptoms or signs of infection | up to 3 months | 
| Number of episodes of nephrotoxicity |  | up to 3 months | 
| Number of episodes of other toxicities | Toxicities will be defined according to the common terminology criteria for adverse events | up to 3 months | 
| Occurrence of any complication during hospital stay or follow-up |  | up to 3 months | 
| Number of re-hospitalizations due to a complication related to the initial infection |  | within 7 days of discharge | 
| Antibiotic treatment duration |  | up to 3 months | 
| Length of hospital stay |  | up to 3 months | 
| Total 3-month costs |  | at 3 months | 
| Number of deaths related to infection | Death related to infections will be defined according to the physician in charge of the patient | at 3 months | 
| Number of in-hospital death |  | up to 3 months | 
| Survival status |  | at day 90 | 
| Health related quality of life | Quality of life will be assessed using the EQ5D5L scale. The EQ5D5L scale is composed of two parts: a descriptive system and the EQ Visual Analog Scale (EQ VAS). The descriptive system has five dimensions. Each dimension has five levels: no problems, mild problems, moderate problems, severe problems and extreme problems. The descriptive system ranges from 1 to 25, the higher the score the worse the quality of life. The score goes from VAS 0 to 100, the higher the VAS score the better the quality of life. | at inclusion | 
| Health related quality of life. | Quality of life will be assessed using the EQ5D5L scale. The EQ5D5L scale is composed of two parts: a descriptive system and the EQ Visual Analog Scale (EQ VAS). The descriptive system has five dimensions. Each dimension has five levels: no problems, mild problems, moderate problems, severe problems and extreme problems. The descriptive system ranges from 1 to 25, the higher the score the worse the quality of life. The score goes from VAS 0 to 100, the higher the VAS score the better the quality of life. | at day 30 | 
| Health related quality of life. | Quality of life will be assessed using the EQ5D5L scale. The EQ5D5L scale is composed of two parts: a descriptive system and the EQ Visual Analog Scale (EQ VAS). The descriptive system has five dimensions. Each dimension has five levels: no problems, mild problems, moderate problems, severe problems and extreme problems. The descriptive system ranges from 1 to 25, the higher the score the worse the quality of life. The score goes from VAS 0 to 100, the higher the VAS score the better the quality of life. | at 3 months |