Outpatient Antimicrobial Protocol for Febrile Neutropenia: A Nonrandomized Prospective Trial Using Ceftriaxone, Amikacin, and Oral Adjuvant Agents

Abstract

Broad-spectrum antimicrobial therapy has revolutionized the management of febrile neutropenia (FN) in cancer patients. In vogue is an effective therapy an an outpatient basis. One thousand three hundred episodes of FN observed in 70 pediatric solid tumors (STs) and 65 cases of hematomalignancy (HM) at a median age of 5.5 years were treated with a protocol using once-a-day injectable ceftriaxone plus amikacin and other oral adjuvant antimicrobial agents. The mean duration of FN in the ST group was 4.0 +/- 1.2 days and in the HM group was 5.0 +/- 2.5 days. The mean duration of antimicrobial cover in the ST group was 5.0 +/- 1.75 days and in the HM group was 6.0 +/- 1.5 days. The overall recrudescence rate was 6% and the mean duration to recrudescence was 4 +/- 1.5 days (range 3-6 days). The objectives of this protocol were cost reduction and utilization of the available inpatient resources optimally by reducing the pressures of hospitalization for febrile neutropenia. We concluded that a selected group of patients with FN can be effectively managed with this regimen on an outpatient basis.

Evolving concepts of management of febrile neutropenia in children with cancer

“…The three deaths occurred among the patients who were not low-risk because of advanced cancer [4,8,44]. In recent studies that specify comorbidities there have been no life-threatening or fatal complications [18,23,[45][46][47].…”

“…In Studies 12-16, the outpatient setting was a clinic or short-stay unit where the patient was observed for up to 24 hr followed by daily outpatient visits; in Studies 17 and 18, the patients were discharged from the emergency department to home [46,47]. In the very large study of Sahu et al, medically stable Indian patients received ceftriaxone and amikacin plus oral antiviral or antifungal antibiotics as clinically indicated [45]. The failure rate of 6% included patients with fever and neutropenia longer than 7 days; 34% of failures were for positive blood cultures with pseudomonas being the most common species.…”

Outpatient Management of Febrile Neutropenia in Children with Cancer

“…The initial intravenous antibacterial regimens that were complications during outpatient management, compared with employed in studies evaluating home treatment of febrile neutrothose with solid tumors. A large retrospective review of pediatric penia include the following: ceftriaxone + amikacin, [24,26] amikafebrile neutropenia that compared the outcomes of patients with cin + piperacillin, [16] an aminoglycoside + ticarcillin and vancoleukemia to patients with solid tumor also supports this finding. [35] mycin or vancomycin + ceftazidime, [22] ceftriaxone monother-Since the majority of the above trials only included children apy, [25,27,28,31] ceftazidime monotherapy, [13,27,30] ceftazidime ± without significant comorbidity and with a functional marrow, it is vancomycin, [19] ceftazidime + teicoplanin or imipenem monotherlikely this negated any impact of the underlying malignancy on apy, [15] ticarcillin + gentamicin + cloxacillin, [17] or piperacillin + febrile neutropenia outcome.…”

“…The authors conmalignancies. [26] Patients were included in the study if they were cluded that management of a low risk febrile neutropenia populaclinically stable and did not have evidence of pulmonary infiltrates tion in an outpatient setting might be safe and effective. on presentation.…”

Ceftriaxone for the Treatment of Febrile Episodes in Nonneutropenic Patients with Hematooncological Disease or HIV Infection: Comparison of Outpatient and Inpatient Care

“…In a nonrandomized prospective study, Sahu et al [17] investigated once-daily use of ceftriaxone in combination with amikacin for outpatient treatment. The study evaluated 1,300 febrile episodes between 1994 and 1996.…”