Ambulatory Outpatient Management of patients with low risk febrile neutropaenia

Cooksley, Tim; Holland, Mark; Klastersky, Jean

doi:10.52964/amja.0529

Cited by 25 publications

(8 citation statements)

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“…4,7 This can then be used to identify those patients who are potentially suitable for early-supported discharge and management in an ambulatory setting. 10,11 The re-admission rate in our study was 10% and none of the patients required escalation to critical care. This is in line with published literature, which shows a re-admission rate of 5-20%.…”

Section: Discussionmentioning

confidence: 50%

“…9 A number of studies have investigated using the MASCC score to identify patients who are at low risk, by having a MASCC score ≥21, and therefore could be considered for management in an ambulatory setting. 10,11 This has been shown to be a safe and cost effective way to manage these patients. 12,13 In the Oncology community this scoring system has been in place for many years but is still in its infancy amongst non-specialist hospitals.…”

Section: Introductionmentioning

confidence: 99%

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Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK

et al. 2019

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Neutropenic sepsis can be life threatening, with mortality 2-21%. The heterogeneity of patients referred with “suspected neutropenic sepsis” has led to strategies being developed to risk-stratify patients and identify those with a low risk of septic complications that could be managed in the outpatient setting, such as The Multinational Association for Supportive Care in Cancer score (MASCC). Outcomes for patients referred with suspected neutropenic sepsis were assessed before and after use of MASCC guided early-supported discharge. 50/123 (41%) patients over 24 months were eligible for early-supported discharge. 26/50 patients had same-day discharge, 14 had overnight admission, 8 stayed 2 nights and 2 stayed 3 nights. Patients received on average 2 follow-up telephone consultations. There were 5 readmissions (10%) and no adverse events. In comparison group; 8 patients over 3-months would have been suitable, potentially saving 40 bed-days. This shows MASCC guided early-supported discharge is safe and cost-effective.

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Section: Discussionmentioning

confidence: 50%

Section: Introductionmentioning

confidence: 99%

Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK

et al. 2019

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“…Outpatient ambulatory care for emergency patients with a low-risk febrile neutropenia has already been proven as safe and effective [27]. However, there are challenges regarding the delivery of outpatient care that can mean it is not feasible for all patients, with transport issues being a key constraint [15].…”

Section: Discussionmentioning

confidence: 99%

“…Neutropenia is a common side effect of conventional cytotoxic chemotherapy, with standard-dose regimens typically causing a nadir around 7-10 days, which can incur around 7 days of neutropenia [14]. There are thought to be around 8 cases per 1000 patients who are receiving chemotherapy who develop neutropenic sepsis [15]. Improved management of neutropenic sepsis has been shown to improve morbidity and mortality rates [16].…”

Section: Literature Reviewmentioning

confidence: 99%

Neutropenia Incidence: A Retrospective Analysis of Clinical Data of Cancer Patients Receiving Systemic Anti-Cancer Therapy to Assess the Impact on Treatment Pathways

2021

Int J Nurs Health Care Res

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Background: Cancer represents a major health issue and economic burden to healthcare systems worldwide. Almost one third of people who have cancer will receive systemic anti-cancer therapy, which can result in treatment toxicities, such as neutropenia, that patients must navigate. Identifying those at highest risk of neutropenia related complications to refine existing clinical pathways can not only improve the patient experience, but also increase efficiency of hospital resources.Objective: To explore the incidence of patients with solid tumours who have their systemic anti-cancer therapy deferred due to neutropenia or attend the cancer center unwell post treatment. Method:A retrospective analysis of clinical data extracted from electronic patient records and electronic prescribing systems for specific time periods. Findings:The total number of deferrals due to neutropenia were 7% (n = 224) in the last quarter of 2019 and 5% (n = 169) in the last quarter of 2020. The total 2020 data showed the infection care pathway was triggered by 980 patients. The majority (70%, n = 686) had received systemic anti-cancer therapy for a solid tumour within the last six weeks. Of these, 11% (n = 74) were neutropenic. Conclusion:The highest incidence of neutropenia related complications was seen in patients with breast, gynecological and lower gastrointestinal cancers. However, the numbers of patients with confirmed neutropenia are low.

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“…This has included management of low-risk NS although it has only been implemented by a limited number of UK cancer centres. 40,41 Some have reported results from longitudinal patient series. Marshall et al 42 reported a series of 100 patients from a large UK tertiary cancer centre over a 2-year period with NS who were assessed and given a first dose of i.v.…”

Section: Acute Oncology Service Developmentmentioning

confidence: 99%

Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis: the EASI-SWITCH RCT

Coyle,

Forde,

Adams

et al. 2024

Health Technol Assess

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Background Neutropenic sepsis is a common complication of systemic anticancer treatment. There is variation in practice in timing of switch to oral antibiotics after commencement of empirical intravenous antibiotic therapy. Objectives To establish the clinical and cost effectiveness of early switch to oral antibiotics in patients with neutropenic sepsis at low risk of infective complications. Design A randomised, multicentre, open-label, allocation concealed, non-inferiority trial to establish the clinical and cost effectiveness of early oral switch in comparison to standard care. Setting Nineteen UK oncology centres. Participants Patients aged 16 years and over receiving systemic anticancer therapy with fever (≥ 38°C), or symptoms and signs of sepsis, and neutropenia (≤ 1.0 × 109/l) within 24 hours of randomisation, with a Multinational Association for Supportive Care in Cancer score of ≥ 21 and receiving intravenous piperacillin/tazobactam or meropenem for < 24 hours were eligible. Patients with acute leukaemia or stem cell transplant were excluded. Intervention Early switch to oral ciprofloxacin (750 mg twice daily) and co-amoxiclav (625 mg three times daily) within 12–24 hours of starting intravenous antibiotics to complete 5 days treatment in total. Control was standard care, that is, continuation of intravenous antibiotics for at least 48 hours with ongoing treatment at physician discretion. Main outcome measures Treatment failure, a composite measure assessed at day 14 based on the following criteria: fever persistence or recurrence within 72 hours of starting intravenous antibiotics; escalation from protocolised antibiotics; critical care support or death. Results The study was closed early due to under-recruitment with 129 patients recruited; hence, a definitive conclusion regarding non-inferiority cannot be made. Sixty-five patients were randomised to the early switch arm and 64 to the standard care arm with subsequent intention-to-treat and per-protocol analyses including 125 (intervention n = 61 and control n = 64) and 113 (intervention n = 53 and control n = 60) patients, respectively. In the intention-to-treat population the treatment failure rates were 14.1% in the control group and 24.6% in the intervention group, difference = 10.5% (95% confidence interval 0.11 to 0.22). In the per-protocol population the treatment failure rates were 13.3% and 17.7% in control and intervention groups, respectively; difference = 3.7% (95% confidence interval 0.04 to 0.148). Treatment failure predominantly consisted of persistence or recurrence of fever and/or physician-directed escalation from protocolised antibiotics with no critical care admissions or deaths. The median length of stay was shorter in the intervention group and adverse events reported were similar in both groups. Patients, particularly those with care-giving responsibilities, expressed a preference for early switch. However, differences in health-related quality of life and health resource use were small and not statistically significant. Conclusions Non-inferiority for early oral switch could not be proven due to trial under-recruitment. The findings suggest this may be an acceptable treatment strategy for some patients who can adhere to such a treatment regimen and would prefer a potentially reduced duration of hospitalisation while accepting increased risk of treatment failure resulting in re-admission. Further research should explore tools for patient stratification for low-risk de-escalation or ambulatory pathways including use of biomarkers and/or point-of-care rapid microbiological testing as an adjunct to clinical decision-making tools. This could include application to shorter-duration antimicrobial therapy in line with other antimicrobial stewardship studies. Trial registration This trial is registered as ISRCTN84288963. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/140/05) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

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Ambulatory Outpatient Management of patients with low risk febrile neutropaenia

Cited by 25 publications

References 0 publications

Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK

Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK

Neutropenia Incidence: A Retrospective Analysis of Clinical Data of Cancer Patients Receiving Systemic Anti-Cancer Therapy to Assess the Impact on Treatment Pathways

Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis: the EASI-SWITCH RCT

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