Positive impact of selective outpatient management of high-risk acute myelogenous leukemia on the incidence of septicemia

Abstract

Background: Curative intent chemotherapy for acute myelogenous leukemia (AML) leads to prolonged severe neutropenia, during which patients are highly susceptible to infection. Traditionally these high-risk patients were treated as inpatients. Our center recently implemented a selective ambulatory management policy for AML patients undergoing chemotherapy. Materials and methods:A retrospective analysis was conducted to assess the occurrence of septicemia in AML patients treated over a 5 years period with curative intent chemotherapy. This review encompasses a change in policy from primarily inpatient care to selective outpatient management coupled with prophylactic antibiotic therapy.Results: A total of 294 patients, receiving 623 cycles of chemotherapy were identified. A significant decrease in septicemia was observed from the inpatient to outpatient cohort (22% to 13% P < 0.05), which correlated with the shift towards outpatient treatment of consolidation cycles. A shift from Gram-negative to Gram-positive organisms as the cause of septicemia was also detected in the outpatient cohort, likely due to the introduction of ciprofloxacin prophylaxis. No significant emerging resistance and no septicemia-related mortality were noted in the outpatient cohort. Conclusion:The observed decrease in the incidence of septicemia in the ambulatory cohort adds supportive evidence to the feasibility of selective outpatient management of AML patients with respect to infectious complications.

Outpatient management following intensive induction chemotherapy for myelodysplastic syndromes and acute myeloid leukemia: a pilot study

“…Patients were discharged on levofloxacin, fluconazole, and acyclovir (or similar medications) and continued until ANC was 0.5¥10 9 or over. Patients were seen by an outpatient oncology nurse three times per week and by a physician once weekly.…”

“…Patients were seen by an outpatient oncology nurse three times per week and by a physician once weekly. Transfusion thresholds in asymptomatic patients were: hematocrit less than 26% and platelet count less than 10¥10 9 . Patients with febrile neutropenia were hospitalized for intravenous antibiotics.…”

“…Few studies have investigated outpatient management for patients undergoing remission induction chemotherapy for AML. [5][6][7][8][9][10] We, therefore, conducted a pilot study that allowed discharge of adult AML/MDS patients once induction chemotherapy was completed to explore the safety and potential cost savings of such a strategy.…”

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

“…These infections require intravenous broad‐spectrum antibiotics 1, 4, 6, 10, as well as antibiotic prophylaxis (AP) during neutropenia, which has been shown to improve infection prevention and overall survival 2. Non‐randomized studies show that treatment of acute leukemia can be performed on an outpatient basis, allowing the patient to remain at home while under supervision in the active treatment phase and neutropenia period 11, 12, 13, 14, 15, 16, 17, 18, 19. Though feasible and safe, findings from our outpatient management study for acute leukemia showed that neutropenic fever followed by septicemia and pneumonia are the dominant causes of readmission during outpatient management 20.…”

Evaluation of a Once-Daily Vancomycin Regimen in an Outpatient Leukemia/Bone Marrow Transplant Clinic (OD-VANCO Study)

“…Ambulatory care has been well described for patients who have undergone autologous hematopoietic stem cell transplant or allogeneic non-myeloablative hematopoietic stem cell transplant, as well as patients with acute leukemia who are discharged before neutrophil recovery and patients receiving treatment for high-risk febrile neutropenia. [3][4][5][6] The outpatient program provides care to both patients with high-risk febrile neutropenia and patients with non-neutropenic immunocompromised states.…”