Acil Serviste Nötropenik Ateşli Hastalarda MASCC ve CISNE Skorlarının Klinik Karşılaştırılması

Abstract

Amaç: Febril nötropeni acil serviste iyi yönetilmesi gereken önemli bir durumdur. Hastaların ev tedavisi ve hastane yatış gerekliliği bazı risk sınıflamalarına göre yapılmaktadır. En sık kullanılan MASCC skoru erken taburculuk yönünden riskler içerebilmektedir. Bu çalışmadaki amacımız MASCC skorunun CİSNE skoru ile desteklenmesi durumunda bu risklerin azaltılabileceğini göstermektir. Ayrıca prokalsitonin değerlerinin bu sınıflamalara katkısını belirlemektir. Gereç ve Yöntem: 2019-2020 yılları arasında acil servise gelen 18 yaş üstü nötropenik ateşli hastalar çalışmaya dahil edildi. Hastaların MASCC ve CİSNE skorları hesaplandı. Skorlar ile mortalite ilişkisi incelendi. MASCC ve CİSNE skorunun birlikte kullanılarak mortalite tahmini yapıldı. Ayrıca proklasitonin değerlerine göre hastalar 4 gruba ayrıldı. Gruplar arası MASCC, CİSNE ve mortalite ilişkisi incelendi. Bulgular: Çalışmaya dahil edilen 103 hastanın %70,9’u erkekti. En sık başvuru nedeni %22,3 ile akut gastroenterit olarak bulundu. Hastaların %40,8’i öldü. MASCC skoruna göre %35,9 oranında hasta yüksek riskli bulundu. Buna rağmen %85,4’ü hastaneye yatırılarak tedavi altına alındı. MASCC ile ters yönlü, orta dereceli istatistiksel olarak önemli korelasyon vardı (r=-0.542, p=0.000), CISNE ile zayıf istatistiksel olarak önemli korelasyon vardı (r=0.385, p=0.000). Akut faz göstergelerinden prokalsitonin ile mortalite arasında orta derece anlamlı bir korelasyon vardı (r=-0.555, p=0.000). Sonuç: Nötropenik ateşli hastaları acil serviste yüksek riskli olanları MASCC skoru ile düşük riskli hastaları ise CISNE skoru ile değerlendirmek kötü prognozu belirlemede daha doğru sonuçlar veriyor. Bu iki skor eğer prokalsitonin ile birlikte değerlendirilirse hastane dışı mortalite oranı daha da azaltılabilir. Bunun için risk skorlarının prokalsitonin gibi bir belirteçle modifiye edildiği prospektif çalışmalara ihtiyaç var.

Keywords

• CİSNE skoru,
• Febril nötropeni,
• MASCC skoru,
• Mortalite,
• Prokalsitonin

Project Number

None

Clinical Comparison of MASCC and CISNE Scores in Neutropenic Febrile Patients in the Emergency Department

Abstract

Objective: Febrile neutropenia is an important condition that needs to be well managed in the emergency department. Home treatment and hospitalization requirements of the patients are made according to some risk classifications. The most commonly used MASCC score may involve risks in terms of early discharge. Our aim in this study is to show that these risks can be reduced if the MASCC score is supported by the CISNE score. In addition, it is to determine the contribution of procalcitonin values to these classifications. Material and Method: Neutropenic febrile patients over the age of 18 who came to the emergency department between 2019 and 2020 were included in the study. MASCC and CISNE scores of the patients were calculated. The relationship between scores and mortality was examined. Mortality estimation was made by using MASCC and CISNE scores together. In addition, patients were divided into 4 groups according to their proclacytonin values. The relationship between MASCC, CISNE and mortality between the groups was examined. Results: Of the 103 patients included in the study, 70.9% were male. The most common reason for admission was found to be acute gastroenteritis with 22.3%. 40.8% of the patients died. According to the MASCC score, 35.9% of the patients were found to be at high risk. Despite this, 85.4% of them were hospitalized and treated. There was an inverse, moderate statistically significant correlation with MASCC (r=-0.542, p=0.000), and a weak statistically significant correlation with CISNE (r=0.385, p=0.000). There was a moderately significant correlation between procalcitonin, one of the acute phase indicators, and mortality (r=-0.555, p=0.000). Conclusion: Evaluating neutropenic febrile patients with MASCC score for high-risk patients and CISNE score for low-risk patients in the emergency department gives more accurate results in determining poor prognosis. If these two scores are evaluated together with procalcitonin, the out-of-hospital mortality rate can be further reduced. For this, prospective studies in which risk scores are modified with a marker such as procalcitonin are needed.

Keywords

• CISNE score
• Febrile Neutropenia,
• MASCC score,
• Mortality,
• Procalcitonin

Supporting Institution

None

Project Number

None

Thanks

None

References

1. Zimmer AJ, Freifeld AG. Optimal management of neutropenic fever in patients with cancer. J Oncol Pract. 2019;15(1):19-24. doi: 10.1200/JOP.18.00269.
2. Bochennek K, Luckowitsch M, Lehrnbecher T. Recent advances and future directions in the management of the immunocompromised host. Semin Oncol. 2020;47(1):40–47. doi: 10.1053/j.seminoncol.2020.02.005.
3. Taplitz RA, Kennedy EB, Bow EJ, Crews J, Gleason C, Hawley DK, et al. Outpatient management of fever and neutropenia in adults treated for malignancy: american society of clinical oncology and ınfectious diseases society of america clinical practice guideline update. J Clin Oncol. 2018;36(14):1443-1453. doi: 10.1200/JCO. 2017.77.6211.
4. Smith TJ, Bohlke K, Lyman GH, Carson KR, Crawford J, Cross SJ, et al. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2015 Oct 1. 33 (28):3199-3212. doi:10.1200/JCO. 2017.77.6211.
5. Cooksley T, Font C, Scotte F, Escalante C, Johnson L, Anderson R, et al. Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper. Support Care Cancer. 2021;29(2):1129-1138. doi: 10.1007/s00520-020-05906-y.
6. Çetintepe T, Çetintepe L, Solmaz Ş, Çalık Ş, Uğur MC, Gediz F, et al. Determination of the relationship between mortality and SOFA, qSOFA, MASCC scores in febrile neutropenic patients monitored in the intensive care unit. Support Care Cancer. 2021;29(7):4089-4094. doi: 10.1007/s00520-020-05924-w.
7. Maisner M. Procalcitonin-a new, innovative infection parameter biochemical and clinical aspects. 3. revised and expanded edition. (Thieme, Stuttgart, New York), 2000.
8. İpekci A, Kanbakan A, Akdeniz YS, Çakmak F, Biberoğlu S, Ozkan S, et al. Scoring systems ıdentifying the low-risk febrile neutropenia patients in the emergency department: usefulness of MASCC, CISNE and qSOFA. Phnx Med J. 2021;3(3):118-122. doi: 10.38175/phnx.992230

9. van der Velden WJ, Herbers AH, Netea MG, Blijlevens NM. Mucosal barrier injury, fever and infection in neutropenic patients with cancer: introducing the paradigm febrile mucositis. Br J Haematol. 2014;167(4):441-452. doi: 10.1111/bjh.13113.
10. Ferrant A. Bacteraemia in febrile neutropenic cancer patients. International Journal of Antimicrobial Agents. 2007;30S:S51–S59. doi:10.1016/j.ijantimicag.2007.06.012.
11. Coyne CJ, Le V, Brennan JJ, Castillo EM, Shatsky RA, Ferran K, et al. Application of the MASCC and CISNE risk-stratification scores to ıdentify low-risk febrile neutropenic patients in the emergency department. Ann Emerg Med. 2016:1-10. doi: 10.1016/j.annemergmed.2016.11.007.
12. Moon H, Choi YJ, Sim SH. Validation of the Clinical Index of Stable Febrile Neutropenia (CISNE) model in febrile neutropenia patients visiting the emergency department. Can it guide emergency physicians to a reasonable decision on outpatient vs. inpatient treatment? PLoS ONE. 2018;13(12): e0210019. doi: 10.1371/journal.pone.0210019.
13. Lucas AJ, Olin JL, Coleman MD. Management and preventive measures for febrile neutropenia. P T. 2018;43(4):228-232.
14. Ahn S, Lee YS. Predictive factors for poor prognosis febrile neutropenia. Curr Opin Oncol. 2012;24(4):376-380. doi: 10.1097/CCO.0b013e328352ead2.
15. Keskin AS, Atakent D, Çelebi G, Pişkin N, Aydemir H, Çuvalcı NÖ, et al. The diagnostic and prognostic value of procalcitonin level ın patients with systemic ınflammatory response syndrome and septic shock symptoms. Gevher Nesibe Journal of Medical & Health Sciences. 2020;5(8):45-52. doi: 10.46648/gnj.101.