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    MASCC Risk Index for Febrile Neutropenia

    Identifies patients at low risk for poor outcome with febrile neutropenia.
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    INSTRUCTIONS

    Use in neutropenic patients (see ANC calculator) with fever at least 100.4°F (38ºC). Do not use in patients with acute leukemia undergoing induction chemotherapy or allogeneic hematopoietic stem cell transplant conditioning, per IDSA guidelines.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Use at fever onset to assess risk of complications in febrile neutropenia for patients undergoing chemotherapy treatment.
    • Use after addressing immediate concerns to identify patients who may not need to be admitted to the hospital or could be discharged early.
    • Only applies to adult patients.
    • Validated as a dichotomous outcome; i.e., low risk versus not low risk. Obviously, patients who are “not low risk” have varying degrees of risk.

    Febrile neutropenia is a potentially life-threatening complication of chemotherapy, but some patients are at low risk for serious complications. The MASCC Risk Index is an internationally validated scoring system that identifies these low risk patients that can potentially be treated as an outpatient with early antibiotics.

    None or mild
    +5
    Moderate
    +3
    Severe
    0
    No
    +5
    Yes
    0
    No
    +4
    Yes
    0
    Solid tumor
    +4
    Hematologic, no prior fungal infection
    +4
    Hematologic, prior fungal infection
    0
    No
    +3
    Yes
    0
    Outpatient
    +3
    Inpatient
    0
    <60
    +2
    ≥60
    0

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    Higher scores indicate lower risk, with a maximum of 26 points.  Using a cutoff value of >21 points discriminates patients with low risk from those with high risk (<21 points) for serious complications of febrile neutropenia, e.g. death, ICU admission, hypotension (see Formula for complete list).

    Management

    • The MASCC has been endorsed by the Infectious Disease Society of America (IDSA) since 2002 with Level B (moderate) evidence supporting its use. However, most experts consider high risk patients to be those with anticipated prolonged neutropenia (>7 days), profound neutropenia (ANC <100) and/or co-morbid conditions (in addition to COPD)—Level A evidence—that are not necessarily accounted for in the MASCC. Therefore, clinical judgment by specialists (infectious disease, hematology/oncology or emergency medicine/internal medicine/critical care) with knowledge of predicted disease-specific chemotherapy effects may override the MASCC Score.
    • High risk patients require admission for IV antibiotics.
    • Carefully-selected low risk patients should receive oral or IV empiric antibiotics in a clinic or hospital setting and may be transitioned to outpatient regimens if they meet certain criteria (see algorithm below).  

    *Adapted from the IDSA Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer, 2010.

    Critical Actions

    IDSA recommends admission for empiric antibiotics for high-risk patients not already admitted to the hospital.

    Formula

    Addition of the selected points:

     

    0 points

    2 points

    3 points

    4 points

    5 points

    Burden of illness (symptom severity)

    Severe

    --

    Moderate

    --

    None or mild

    Hypotension

    (sBP <90 mmHg)

    Yes

    --

    --

    --

    No

    Active COPD

    Yes

    --

    --

    No

    --

    Solid tumor (or hematological malignancy without prior fungal infection)

    No

    --

    --

    Yes

    --

    Dehydration requiring IV therapy

    Yes

    --

    No

    --

    --

    Status at onset of fever

    Inpatient

    --

    Outpatient

    --

    --

    Age

    ≥60 years

    <60 years

    --

    --

    --

    “Poor outcome” was defined as any of the following:

    • Hypotension: systolic blood pressure <90 mmHg or need for pressor support to maintain BP.
    • Respiratory failure: PaO2 <60 mmHg while breathing room air, or need for mechanical ventilation.
    • ICU admission.
    • Disseminated intravascular coagulation.
    • Confusion or altered mental state.
    • CHF seen on chest x-ray and requiring treatment.
    • Bleeding severe enough to require transfusion.
    • Arrhythmia or EKG changes requiring treatment.
    • Renal failure requiring investigation and/or treatment with IV fluids, dialysis, or any other intervention.
    • Other complications judged serious and clinically significant by the investigator.

    Facts & Figures

    Interpretation:

    MASCC Risk Index

    Risk for febrile neutropenia

    Recommendation*

    >21

    Low risk

    Consider oral and/or outpatient empirical antibiotic therapy.

    ≤21

    High risk

    Admit for empiric antibiotics if not already inpatient.

    *From the IDSA Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer, 2010.

    Evidence Appraisal

    The derivation study for the MASCC Risk Index was performed in the late 1990s (1994-1997) and included 756 patients in the derivation cohort and 383 in the validation cohort. While many claim that the MASCC cannot be applied to patients with hematologic malignancies, over 40% of the patients included had a hematologic malignancy. Logistic regression analysis was used to determine a weighted risk score with a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%.

    Of note, patients were only included in the study for a single episode of febrile neutropenia and were not allowed to re-enter the study for subsequent episodes; thus, it is unclear if the score should be applied to patients with multiple episodes of febrile neutropenia (though it is routinely done in clinical practice).

    There have been at least 8 external validation studies showing a positive predictive value (PPV) from 83-98% with sensitivity from 59-95%. Studies that included more patients with hematologic malignancies had lower PPV and sensitivity suggesting a poorer performance of the score in that population.

    Literature

    Validation

    Research PaperUys A, Rapoport BL, Anderson R. Febrile neutropenia: a prospective study to validate the Multinational Association of Supportive Care of Cancer (MASCC) risk-index score. Support Care Cancer. 2004;12(8):555-60.Research PaperKlastersky J, Paesmans M, Georgala A, et al. Outpatient oral antibiotics for febrile neutropenic cancer patients using a score predictive for complications. J Clin Oncol. 2006;24(25):4129-34.Research PaperCherif H, Johansson E, Björkholm M, Kalin M. The feasibility of early hospital discharge with oral antimicrobial therapy in low risk patients with febrile neutropenia following chemotherapy for hematologic malignancies. Haematologica. 2006;91(2):215-22.Research PaperInnes H, Lim SL, Hall A, Chan SY, Bhalla N, Marshall E. Management of febrile neutropenia in solid tumours and lymphomas using the Multinational Association for Supportive Care in Cancer (MASCC) risk index: feasibility and safety in routine clinical practice. Support Care Cancer. 2008;16(5):485-91.Research PaperBaskaran ND, Gan GG, Adeeba K. Applying the Multinational Association for Supportive Care in Cancer risk scoring in predicting outcome of febrile neutropenia patients in a cohort of patients. Ann Hematol. 2008;87(7):563-9.Research PaperHui EP, Leung LK, Poon TC, et al. Prediction of outcome in cancer patients with febrile neutropenia: a prospective validation of the Multinational Association for Supportive Care in Cancer risk index in a Chinese population and comparison with the Talcott model and artificial neural network. Support Care Cancer. 2011;19(10):1625-35.Research PaperCarmona-bayonas A, Gómez J, González-billalabeitia E, et al. Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients. Br J Cancer. 2011;105(5):612-7.
    Dr. Jean Klastersky

    About the Creator

    Jean Klastersky, MD, is a professor of medicine at the University of Brussels. He is also currently the chief of medicine services at the Institut Jules Bordet. Dr. Klastersky's research focuses on treatment and prognosis in neutropenic fever and novel therapies in cancer patients.

    To view Dr. Jean Klastersky's publications, visit PubMed

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