Early hospital discharge with oral antimicrobial therapy in patients with hematologic malignancies and low-risk febrile neutropenia

Abstract

Although consensus exists relating criteria for the identification of low-risk patients with febrile neutropenia, no clear indication on how to manage these patients has been so far provided particularly in outpatients affected by hematologic malignancies. The feasibility and safety of early discharge was prospectively evaluated in 100 outpatients with hematologic malignancies and febrile neutropenia. A strategy considering the risk-index of the Multinational Association of Supportive Care in Cancer (MASCC) was applied. High-risk patients were entirely managed at hospital. Low-risk patients were early discharged if they were afebrile since 48 h and not on supportive therapy requiring hospitalization. Out of 90 low-risk episodes, in 69 instances (76.7%), patients were discharged after a median of 4 days and continued home therapy with oral cefixime (78%) or other antibiotics. Only five outpatients (7.2%) had fever recurrence. Twenty-one low-risk patients were not early discharged due to worsening conditions (three deaths), need of multiple daily dose therapy, or discharge refuse. No clinical characteristic was able to predict the eligibility for early discharge. The MASCC risk-index is a useful aid in the identification of high-risk febrile neutropenia needing whole in-hospital treatment. As for low-risk patients, hospitalization at least in the first days of fever is required. Cefixime could be included among the oral antibacterial drugs to be used in the outpatient treatment of adult patients with febrile neutropenia.

Outpatient Management of Acute Myeloid Leukemia after Intensive Consolidation Chemotherapy Is Feasible and Reduces Hospital Treatment Costs

“…In the remaininginstances,causesforreadmissionincludedconstitutional symptoms, mucositis with pain, diarrhea and minor bleeding(CTCgrade1-2).Importantly,inagreementwithrecentreports [13][14][15]24],wedidnotobservedifferencesinthe incidence of CTC grade 3 and 4 toxicities, and specifically neutropenicfebrileepisodes,betweenreadmissioncyclesand outpatient cycles. According to a recent study published by Halimetal.…”

Use of risk stratification to guide ambulatory management of neutropenic fever

“…While there is evidence to support immediate outpatient treatment, predominantly with oral antibiotics, for patients with solid tumours and low‐ to intermediate‐grade lymphomas (grade B recommendation), 4,25–31 the supporting data for patients with other haematological malignancies are much fewer. Two haematology studies were identified, one administering parenteral antibiotics for at least 24 h prior to early discharge, the other for at least 48 h 24,32 …”

“…Thus, from the perspective of patient safety, a period of inpatient observation of at least 24 h for patients with solid tumour or low‐ to intermediate‐grade lymphomas is recommended followed by early discharge (grade B recommendation) 5,28,33 . For patients with other haematological malignancy, a period of observation of at least 48 h is recommended followed by early discharge, if appropriate (grade D recommendation) 24,32 . This approach is consistent with published literature 5,32–34 and will also enable the treating team to review preliminary culture results (blood, urine, etc.)…”

Prognostic factors for risk stratification of adult cancer patients with chemotherapy‐induced febrile neutropenia: A systematic review and meta‐analysis

“…The other challenge faced by users revolves around the performance (prediction accuracy) of current prognostic models for FN outcomes. Some of the limitations include inadequate validation, misclassification in the low‐risk group that could compromise patient safety and limited discriminatory ability when used among the subgroup of cancer patients …”