Selective discharge of patients with acute myeloid leukemia during chemotherapy-induced neutropenia

Abstract

Purpose. it is common practice for patients with acute myeloid leukemia (AML) to be observed in hospital during the entire nadir after intensive chemotherapy. in an attempt to lessen the likelihood of developing infections with hospital acquired pathogens, we usually discharge patients upon completion of chemotherapy and follow them as outpatients. They are readmitted if fever develops. We evaluated the feasibility and safety of this practice. Patients and Methods. We studied 29 patients with AML (median age 40 years, range 16-63) who were treated with intensive remission-induction and consolidation chemother-apy. Afebriie patients not receiving antibiotics were discharged immediately following chemotherapy and were followed every 3-4 days at the day care unit. Patients were instructed to return immediately if fever rose to 38.2"C or a fever of 38°C persisted for 2 hr. The 29 patlents received a total of 86 courses. Following 50 courses, patients were discharged. These 50 ambulatory nadir periods (ANPs) were monitored. Results. Median WBC and platelet counts on discharge were 2,900 per cubic millimeter (range 3004,300) and 137,000 per cubic millimeter (range 17,000-61 8,000), respectively. Mean traveling time from the hospital by car was 1.6 hr (range 15 min-3 hr). In three of the 50 ANPs (So/.), patients were not readmitted during their entire nadir. During 47 of the ANPs, patients returned to the hospital (because of fever in 44 cases), a mean of 7.2 days (range 1.0-12.7 days) after discharge. In 45 ANPs, patients were readmitted in good general condition. Four patients had iife-threatening complications. Two patients were admitted in septic shock due to delay in seeking admission, but rapidly recovered. Two other patients died, one of cardiogenic shock within 24 hr of readmission and one 24 days later. Only one of the 11 gram negative bacteria cultured was resistant to mezlocillin and gentamlcin. After 45 ANPs, patients were discharged a mean of 12.2 days (range 5-42 days) foilowing readmission. We estimate that approximately 383 hospital days were saved by this policy, a mean of 7.6 days per patient, representing 16% of total inpatient hospital days. Conclusions. For AML patients who are reliable and without complicating medical conditions, selected discharge following chemotherapy is a low-risk practice and may reduce the incidence of infection with resistant hospital-acquired pathogens.

A comparison of resource utilization following chemotherapy for acute myeloid leukemia in children discharged versus children that remain hospitalized during neutropenia

“…Another study evaluating outpatient versus inpatient AML intensification chemotherapy found fewer days of febrile neutropenia and less antimicrobial use among outpatients than children receiving inpatient treatment . Likewise, previous evaluations among adult AML patients found outpatient supportive care to be associated with fewer and shorter febrile episodes and fewer days of intravenous antibiotic administration . The findings with respect to antimicrobial agent use contradict those of the current study.…”

“…However, a recent survey of pediatric supportive care practices suggests that up to one‐third of pediatric AML patients are discharged early to outpatient management during postchemotherapy neutropenia . While outpatient supportive care in this population has only been examined in a single study of 26 patients , several studies of adult AML patient populations suggest that outpatient management during neutropenia may be safe and feasible . Early hospital discharge was associated with fewer febrile episodes , reduced use of intravenous antibiotics and comparable mortality .…”

Outpatient intensive induction chemotherapy for acute myeloid leukemia and high-risk myelodysplastic syndrome

“…[9][10][11][12][13] Furthermore, several studies (including 2 at our institution) have shown that early discharge after intensive induction chemotherapy is feasible, safe, and reduces daily charges in selected patients. [14][15][16][17] In contrast, no studies, to the best of our knowledge, have thus far investigated outpatient administration of intensive induction chemotherapy in patients with AML and high-risk MDS. This prompted conduct of the current pilot study to test the feasibility of outpatient intensive induction chemotherapy for select patients with AML and high-risk MDS and to preliminarily assess its impact on resource utilization.…”

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.…”