Written by Meghan Breed
In patients that develop febrile neutropenia, procalcitonin (PCT) levels were better at identifying those at a higher risk for 30-day mortality and bacteremia than the commonly used MASCC score.
Why does this matter?
Febrile neutropenia is a common complication of chemotherapy. Neutropenia is defined as an absolute neutrophil count (ANC) <1500 or 1000 cells/mL, depending on the institution, with severe neutropenia defined as an ANC <500 cells/mL. The Infectious Diseases Society of America defines fever in neutropenic patients as a single oral temperature of >38.3 degrees Celsius or a temperature of >38.0 degrees Celsius sustained over one hour. Identifying those patients that are at low-risk for potential complications of febrile neutropenia who could be safely managed as an outpatient would reduce the burden of hospital admission and eliminate the risk of exposure to nosocomial infections.
I love SoCal, I mean ProCal
100 patients were included in this prospective, observational study to determine 30-day mortality using MASCC score and subsequent PCT levels. Of these 100 patients, 92 had hematologic malignancies and 8 had solid tumors. All patients had an ANC <1000 and a single fever of >38 degrees Celsius. During evaluation in the emergency department, a MASCC score was assigned to each patient, and then blood cultures and a point-of-care PCT were drawn prior to starting antibiotics. Of the 100 patients, 54 were classified as low-risk by MASCC score (≥21). The median value of PCT in patients deemed low-risk (MASCC ≥ 21) was 0.735 ng/mL and with MASCC scores <21 was 1.48 (lower MASCC scores mean greater risk). When PCT levels were drawn in the low risk patient group (N=54), 19 patients had PCT levels above 1.42. Of these 19 patients, 9 died within 30 days. The PCT cutoff value was determined to be 1.42 ng/mL to yield an AUROC of 0.66, which demonstrated higher sensitivity, specificity, PPV and NPV for mortality and bacteremia than MASCC scores. See Table.
I certainly think procalcitonin can be used in the emergency department as an objective data point to aid in the decision to admit or discharge and would remove the subjective component of the MASCC score; however, it is important to note that the study population was relatively young (mean age 30.2), predominantly male (70%), and biased towards hematologic malignancies (92%).
Editor’s note: Neither MASCC nor PCT is a great discriminator to determine which patients are safe for discharge. PCT may have a role, as Dr. Breed mentioned, as one part of the decision making process, in concert with the heme-onc team. Be very cautious with these patients and with the MASCC and CISNE scores. ~Clay Smith
Prognostic Value of Serum Procalcitonin Levels in Patients With Febrile Neutropenia Presenting to the Emergency Department. J Emerg Med. 2021 May;60(5):641-647. doi: 10.1016/j.jemermed.2020.12.010. Epub 2021 Jan 28.