Approach to Treatment of the Febrile Cancer Patient with Low-Risk Neutropenia

Work-up for Fever During Neutropenia for Both the Stem Cell Transplant Recipient and the Hematologic Malignancy Patient

Fever is a common complication in patients with underlying neutropenia and is associated with significant mortality in neutropenic patients with acute myelogenous leukemia or hematopoietic cell transplant. Fever may be the only sign of infection and requires further clinical assessment, including a history, a physical examination, and additional laboratory and radiographic testing. National and international guidelines recommend initiation of empiric antimicrobial therapy in patients with fever during neutropenia. Stepwise escalation of antibacterial therapy, followed by antifungal therapy for patients with persistent fever, generally is recommended. Consideration should also be given to de-escalation of antimicrobial therapy in the appropriate clinical settings.

Outcomes of a clinical pathway for primary outpatient management of pediatric patients with low-risk febrile neutropenia

BACKGROUND

Fever and neutropenia is a common reason for nonelective hospitalization of pediatric oncology patients. Herein we report nearly five years of experience with a clinical pathway designed to guide outpatient management for patients who had low-risk features.

PROCEDURES

Through a multidisciplinary collaboration, we implemented a clinical pathway at our institution using established low-risk criteria to guide outpatient management of pediatric oncology patients. Comprehensive chart review of all febrile neutropenia episodes was conducted to characterize outcomes of patients with low-risk febrile neutropenia following clinical pathway implementation.

RESULTS

Between April 1, 2013, and October 1, 2017, there were 169 cases of febrile neutropenia managed in our Pediatric Oncology Unit. Sixty-seven (40%) of these episodes were defined as low risk and managed either entirely in the outpatient setting (41 episodes, 24%) or with a step-down strategy involving a very brief inpatient stay (26 episodes, 15%). There were no intensive care unit admissions or deaths among the low-risk patients. Of those identified as low risk, seven patients (10%) required subsequent hospitalization during the follow-up period, two for inadequate oral intake, two for persistent fevers, one for cellulitis, one for seizure unrelated to the febrile episode, and one for a positive blood culture.

CONCLUSIONS

Following implementation of a clinical pathway, the majority of patients designated as low risk were managed primarily in the outpatient setting without major morbidity or mortality, suggesting that carefully selected low-risk patients can be successfully treated with outpatient management and subsequent admission if warranted.

Management of Patients With Fever and Neutropenia Through the Arc of Time: A Narrative Review

The association between fever and neutropenia and the risk for life-threatening infections in patients receiving cytotoxic chemotherapy has been known for 50 years. Indeed, infectious complications have been a leading cause of morbidity and mortality in patients with cancer. This review chronicles the progress in defining and developing approaches to the management of fever and neutropenia through observational and controlled clinical trials done by single institutions, as well as by national and international collaborative groups. The resultant data have led to recommendations and guidelines from professional societies and frame the current principles of management. Recommendations include those guiding new treatment options (from monotherapy to oral antibiotic therapy) and use of prophylactic antimicrobial regimens in high-risk patients. Of note, risk factors have changed with the advent of hematopoietic cytokines (especially granulocyte colony-stimulating factor) in shortening the duration of neutropenia, as well as with the discovery of more targeted cancer treatments that do not result in cytotoxicity, although these are still the exception. Most guiding principles that were developed decades ago-about when to begin empirical treatment after a neutropenic patient becomes febrile, whether and how to modify the initial treatment regimen (especially in patients with protracted neutropenia), and how long to continue antimicrobial therapy-are still used today. This review describes how the treatment principles related to the management of fever and neutropenia have responded to changes in the patients at risk, the microbes responsible, and the tools for their treatment, while still being sustained over the arc of time.

Outpatient treatment for people with cancer who develop a low-risk febrile neutropaenic event

BACKGROUND

People with febrile neutropaenia are usually treated in a hospital setting. Recently, treatment with oral antibiotics has been proven to be as effective as intravenous therapy. However, the efficacy and safety of outpatient treatment have not been fully evaluated.

OBJECTIVES

To compare the efficacy (treatment failure and mortality) and safety (adverse events of antimicrobials) of outpatient treatment compared with inpatient treatment in people with cancer who have low-risk febrile neutropaenia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library, MEDLINE via Ovid (from 1948 to November week 4, 2018), Embase via Ovid (from 1980 to 2018, week 48) and trial registries (National Cancer Institute, MetaRegister of Controlled Trials, Medical Research Council Clinical Trial Directory). We handsearched all references of included studies and major reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing outpatient with inpatient treatment for people with cancer who develop febrile neutropaenia. The outpatient group included those who started treatment as an inpatient and completed the antibiotic course at home (sequential) as well as those who started treatment at home.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, methodological quality, and extracted data. Primary outcome measures were: treatment failure and mortality; secondary outcome measures considered were: duration of fever, adverse drug reactions to antimicrobial treatment, duration of neutropaenia, duration of hospitalisation, duration of antimicrobial treatment, and quality of life (QoL). We estimated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data; we calculated weighted mean differences for continuous data. Random-effects meta-analyses and sensitivity analyses were conducted.

MAIN RESULTS

We included ten RCTs, six in adults (628 participants) and four in children (366 participants). We found no clear evidence of a difference in treatment failure between the outpatient and inpatient groups, either in adults (RR 1.23, 95% CI 0.82 to 1.85, I² 0%; six studies; moderate-certainty evidence) or children (RR 1.04, 95% CI 0.55 to 1.99, I² 0%; four studies; moderate-certainty evidence). For mortality, we also found no clear evidence of a difference either in studies in adults (RR 1.04, 95% CI 0.29 to 3.71; six studies; 628 participants; moderate-certainty evidence) or in children (RR 0.63, 95% CI 0.15 to 2.70; three studies; 329 participants; moderate-certainty evidence).According to the type of intervention (early discharge or exclusively outpatient), meta-analysis of treatment failure in four RCTs in adults with early discharge (RR 1.48, 95% CI 0.74 to 2.95; P = 0.26, I² 0%; 364 participants; moderate-certainty evidence) was similar to the results of the exclusively outpatient meta-analysis (RR 1.15, 95% CI 0.62 to 2.13; P = 0.65, I² 19%; two studies; 264 participants; moderate-certainty evidence).Regarding the secondary outcome measures, we found no clear evidence of a difference between outpatient and inpatient groups in duration of fever (adults: mean difference (MD) 0.2, 95% CI -0.36 to 0.76, 1 study, 169 participants; low-certainty evidence) (children: MD -0.6, 95% CI -0.84 to 0.71, 3 studies, 305 participants; low-certainty evidence) and in duration of neutropaenia (adults: MD 0.1, 95% CI -0.59 to 0.79, 1 study, 169 participants; low-certainty evidence) (children: MD -0.65, 95% CI -0.1.86 to 0.55, 2 studies, 268 participants; moderate-certainty evidence). With regard to adverse drug reactions, although there was greater frequency in the outpatient group, we found no clear evidence of a difference when compared to the inpatient group, either in adult participants (RR 8.39, 95% CI 0.38 to 187.15; three studies; 375 participants; low-certainty evidence) or children (RR 1.90, 95% CI 0.61 to 5.98; two studies; 156 participants; low-certainty evidence).Four studies compared the hospitalisation time and found that the mean number of days of hospital stay was lower in the outpatient treated group by 1.64 days in adults (MD -1.64, 95% CI -2.22 to -1.06; 3 studies, 251 participants; low-certainty evidence) and by 3.9 days in children (MD -3.90, 95% CI -5.37 to -2.43; 1 study, 119 participants; low-certainty evidence). In the 3 RCTs of children in which days of antimicrobial treatment were analysed, we found no difference between outpatient and inpatient groups (MD -0.07, 95% CI -1.26 to 1.12; 305 participants; low-certainty evidence).We identified two studies that measured QoL: one in adults and one in children. QoL was slightly better in the outpatient group than in the inpatient group in both studies, but there was no consistency in the domains included.

AUTHORS' CONCLUSIONS

Outpatient treatment for low-risk febrile neutropaenia in people with cancer probably makes little or no difference to treatment failure and mortality compared with the standard hospital (inpatient) treatment and may reduce time that patients need to be treated in hospital.

[Modalities of management of cancer patients with febrile neutropenia in the oncology emergency unit of Gustave-Roussy and their related costs]

BACKGROUND

Febrile neutropenia (FN) is a severe chemotherapy side effect. Hospitalization is recommended for FN episode of high-risk (HR) of complications. Management of FN at lower risk of complications remains unclear.

METHODS

This is a prospective observation study in patients with solid tumors admitted to the emergency department FN. Collected data included demographics, clinical, biological, therapeutic costs, MASCC score and complications.

RESULTS

Hundred and thirty-seven consecutive FN were recorded in 128 patients. Twenty-six FN (19%) were managed at home (all of them had a MASCC score ≥ 21); 111 (81%) were treated at hospital of which 37 NF were at HR of complications based on clinical and biological parameters (all of them had a MASCC score < 21) and for 74 of them the admission could be discussed (MASCC < 20 or ≥ 20). This group of patients was considerate with intermediate risk (IR). All IR patients were treated with the same antibiotics than outpatients, i.e. ceftriaxone in 36 cases (49%) or amoxicillin/clavulanic acid and ciprofloxacin in 38 cases (51%). For these 74 cases, any severe complication was recorded. Antibiotics were adapted for only 12% of these patients according to bacteriology results.

CONCLUSION

This study showed the limits of the MASCC score. We did not observe any severe complications in patients admitted to the hospital according to clinical and biological parameters and with the high risk score MASCC. This study had some methodological bias but it allowed us to estimate the cost of the different ways of management and the difficulties to decide the hospitalization in FN.

Oral versus intravenous antibiotics in treatment of paediatric febrile neutropenia

The purpose of this study is to determine whether, in low-risk febrile neutropenic paediatric populations, oral antibiotics are as effective as intravenous antibiotics in obtaining resolution of the febrile neutropenic episode. A comprehensive literature search of MEDLINE, EMBASE and CENTRAL identified prospective, randomised controlled trials comparing oral antibiotics with intravenous antibiotics in the treatment of febrile neutropenic episodes in low-risk paediatric oncology patients. Outcomes assessed were mortality, rate of treatment failure, length of the febrile neutropenic episode and adverse events. The random effects model was used to calculate risk ratios (RRs) for dichotomous data and mean difference with standard deviation for continuous data. Seven trials were included in the overall analysis, which included 934 episodes of febrile neutropenia in 676 patients aged between 9 months and 20 years. The overall treatment failure rates were not significantly different between oral and intravenous antibiotics (RR: 1.02, 95% confidence interval 0.78-1.32, P= 0.91). In carefully selected low-risk febrile neutropenic children, empiric treatment with oral antibiotics is a safe and effective alternative to intravenous antibiotics as they lower the cost of treatment as well as psychosocial burden on these children and their families.

Procalcitonin and C-reactive protein serum levels as markers of infection in a pediatric population with febrile neutropenia and cancer

BACKGROUND

Procalcitonin and C-reactive-protein are inflammatory markers for sepsis. The authors evaluated their sensitivity and specificity in pediatric patients with cancer and febrile neutropenia.

PROCEDURE

Serum procalcitonin and C-reactive-protein were evaluated. Patients (n = 54) were divided into 2 groups, with severe infection (n = 18) or without documented infection (n = 36).

RESULTS

Procalcitonin and C-reactive protein were significantly higher in the high-risk group. Procalcitonin displayed 72.2% sensitivity and 80.5% specificity. C-reactive-protein had a sensitivity of 77.7% and specificity of 77.2%.

CONCLUSIONS

Procalcitonin is an accurate predictor of bacterial infection in neutropenic children, while C-reactive-protein may be a better screening test in emergency settings.

Risk factors for readmission after initial diagnosis in children with acute lymphoblastic leukemia

BACKGROUND

Specific hospital discharge criteria following the initial diagnosis of children with acute lymphoblastic leukemia (ALL) have not been reported. This retrospective cohort study was designed to identify risk factors for readmission during induction therapy, to assist with development of discharge guidelines.

PROCEDURE

We reviewed the records of 142 consecutive children with newly diagnosed B-precursor ALL and found 129 eligible patients. Chi square, t-test, and multivariate logistic regression analysis were used to compare differences in absolute neutrophil count (ANC), NCI risk status, age, type of corticosteroid administered, and other potential risk factors for readmission during induction therapy.

RESULTS

ANC at initial hospital discharge was the only significant predictor of readmission for fever during induction therapy (P = 0.006) by multivariate analysis. Specifically an ANC <or=200/mm(3) at discharge had the strongest association with readmission for fever (OR 3.3, 95% CI 1.422, 7.729).

CONCLUSION

An ANC >200/mm(3), in a clinically stable patient, is associated with minimal risk of readmission during induction therapy following the initial diagnosis of ALL.

Oral gatifloxacin in the outpatient treatment of children with cancer fever and neutropenia

BACKGROUND

Fever in neutropenic (FN) patients requires immediate broad-spectrum antibiotics, however, such patients do not represent a homogeneous population and the majority of them are at low risk of developing complication. Gatifloxacin (GA) is an alternative, though it has not been thoroughly studied in Pediatrics yet. The aim of this study was to evaluate oral GA in oncology pediatric patients with FN and low risk of infectious complications.

METHODS

We conducted a prospective study in patients submitted to chemotherapy and FN, from the ages of 3 to 21 years old, with solid tumors, acute lymphoid leukemia, and lymphomas without comorbidities and treated as outpatient with oral GA. Safety and adverse effects were monitored.

RESULTS

We evaluated 108 patients with 201 episodes of FN. The average age was 10.8 years, 64.8% of the patients were male. Osteosarcoma accounted for 22% of the episodes, rhabdomyosarcoma for 13%, acute lymphoid leukemia, lymphomas and Ewing sarcoma, for 11% each. Among the 174 episodes exclusively treated as outpatients, the average duration of neutropenia was 4.8 days, the average duration of fever was 2.4 days; the average duration of the treatment was 8.1 days. The treatment was successful in 75.9%, analyzing only the first episodes. No patient died during the study. Adverse events included diarrhea, vomiting, increased liver enzymes, arthralgia, and ECG changes.

CONCLUSION

Oral GA is effective and safe in the management of oncology pediatric patients with FN at low risk of infectious complications in the outpatient setting.

[High and low-risk febrile neutropenic patients]

IDENTIFICATION OF LOW-RISK PATIENTS: These patients exhibit a low probability of dying (risk equal or lesser than 1%) and of developing major complications (risk to the order of 5%). A clinical model developed by Talcott et al. considers at low risk patients at home when the fever starts, without severe co-morbidity and in whom the neoplasia is under control. A prognostic score was established by the MASCC (Multinational Association for Supportive Care in Cancer); it is based on objectively weighted and selected variables. In comparison, the Talcott's classification appears more restrictive (2.5-fold less patients at low risk) but also that it supplies greater safety. IDENTIFICATION OF HIGH-RISK PATIENTS: All the severity scores used in intensive care have their limits. However, the repeated calculation of severity scores (at 48 and 72 hours) might lead to an improvement in their predictive value. The number of organ dysfunction could also be used because the latter provides supplementary clinical information and hence the development of organ dysfunction scores over the past few Years. For febrile neutropenic patients other than in intensive care, the interest of the severity scores and organ dysfunction scores appears limited.

Approche organisationnelle et économique en France du traitement ambulatoire des neutropénies fébriles

A NEW OBJECTIVE: Keeping neutropenic patients with fever in their homes helps to preserve their quality of life and reduces the costs. However, it is important to specify the conditions and the means necessary for the organisation so that home treatment can be applied safely because of the high risk of morbidity due to infection. THE FUNDAMENTAL CONDITIONS FOR ITS MANAGEMENT: The patients who could potentially benefit from an outpatient treatment strategy when presenting with neutropenia and fever must not have a tumour progressing and must not exhibit signs of co-morbidity and be affected by neutropenia and fever at home. Moreover, full information and the patient's and relatives' consent, a hospital nearby, the permanent presence of someone with the patient, the possibility of a telephone contact, the patient's full compliance, prior consent and excellent communication and excellent patient-physician relationship are all essential conditions. THE PARTICIPANTS AT HOME: The patient is essentially followed-up by the treating physician. Private nurses can intervene at the patient's home. Hospitalisation at home is presently the only alternative medical structure to classical hospitalisation. The development of nursing networks ensure the continuity between the hospital and the town and the good coordination of the health workers caring for the patient. The steps to be taken during an episode of fever are debated: complete discharge from hospital for some, initial outpatient controls in the hospital for several hours for others and the initial hospitalisation for 24 to 72 hours for some others. Whatever the case, haemocultures must be performed before the initiation of any antibiotherapy.

SURVEILLANCE

The optimal clinical surveillance is ensured daily by a private nurse and the treating physician. An assessment every 2 to 3 days in a hospital unit is recommended. CARE NETWORKS: Their development should increase and hence create the continuity between the hospital and the town. The outpatient management of neutropenia with fever is a major source of economy; it allows the patients to be kept at home whilst ensuring the quality and security of their treatment.

Ciprofloxacin in treatment of fever and neutropenia in pediatric cancer patients

This article reviews clinical trials of outpatient management of fever and neutropenia in pediatric cancer patients. The syndrome of fever and neutropenia is discussed, and strategies of identifying patients at low risk for complex or fatal infections are described. A number of clinical trials in a wide range of clinical settings and countries have demonstrated that low risk pediatric cancer patients with fever and neutropenia can be prospectively identified and safely treated as outpatients. In addition outpatient management has been shown to be less costly than conventional intravenous therapy in hospitalized patients. Oral fluoroquinolones, including ciprofloxacin, have been used as a component of therapy in several trials because of their ease of administration and their activity against the majority of pathogenic bacteria causing illness in this group. The article also discusses the role of antibiotic prophylaxis of fever and neutropenia in certain high risk settings, such as hematopoietic stem cell transplantation. In selected high risk patients, prophylactic use of limited spectrum fluoroquinolones such as ciprofloxacin may reduce the incidence of Gram-negative bacteremias. Use of fluoroquinolone therapy as prophylaxis, however, is controversial because of concerns about an emergence of resistant organisms. Prudent use of fluoroquinolones as therapy and prophylaxis is essential to prolonging the benefits of this class of compounds.

Effectiveness of combination antimicrobial therapy for Pseudomonas aeruginosa bacteremia

It remains controversial whether combination therapy, given empirically or as definitive treatment, for Pseudomonas aeruginosa bacteremia is associated with a better outcome than monotherapy. The aim of the present study was to compare the rates of survival among patients who received either combination therapy or monotherapy for P. aeruginosa bacteremia. We assembled a historical cohort of 115 episodes of P. aeruginosa bacteremia treated with empirical antipseudomonal therapy between 1988 and 1998. On the basis of susceptibility testing of the bacteremic P. aeruginosa isolate, we defined categories of empirical treatment, including adequate combination therapy, adequate monotherapy, and inadequate therapy, as well as corresponding categories of definitive therapy. Neither the adequacy of the empirical treatment nor the use of combination therapy predicted survival until receipt of the antibiogram. However, the risk of death from the date of receipt of the antibiogram to day 30 was higher for both adequate empirical monotherapy (adjusted hazard ratio [aHR], 3.7; 95% confidence interval [CI], 1.0 to 14.1) and inadequate empirical therapy (aHR, 5.0; 95% CI, 1.2 to 20.4) than for adequate empirical combination therapy. Compared to adequate definitive combination therapy, the risk of death at 30 days was also higher with inadequate definitive therapy (aHR, 2.6; 95% CI, 1.1 to 6.7) but not with adequate definitive monotherapy (aHR, 0.70; 95% CI, 0.30 to 1.7). In this retrospective analysis the use of adequate combination antimicrobial therapy as empirical treatment until receipt of the antibiogram was associated with a better rate of survival at 30 days than the use of monotherapy. However, adequate combination antimicrobial therapy given as definitive treatment for P. aeruginosa bacteremia did not improve the rate of survival compared to that from the provision of adequate definitive monotherapy.

Evolving concepts of management of febrile neutropenia in children with cancer

BACKGROUND

Recent investigations of febrile neutropenia in pediatric cancer patients have identified subsets of low-risk patients who can be managed with less antibiotic therapy than previously recommended standards.

METHODS AND MATERIALS

PubMed and Medline were searched for prospective trials and reviews of febrile neutropenia in children. Magnitude and duration of fever and neutropenia, comorbidities, and therapeutic strategies were examined.

RESULTS

Twenty-seven prospective trials and five reviews were identified. The child with cancer and low-risk febrile neutropenia is clinically well and afebrile within 24-96 hr of antibiotic therapy and has evidence of marrow recovery with a rising phagocyte count. Disqualifying comorbidities include leukemia at diagnosis or in relapse, uncontrolled cancer, age under 1 year, medical condition(s) that would otherwise require hospitalization and social or economic conditions that may potentially compromise access to care or compliance. Therapeutic strategies include parenteral or oral antibiotics in the hospital with early discharge or parenteral antibiotics in the outpatient setting followed by oral or parenteral therapy and daily reassessment. Although as many as 25% of low-risk patients require modification of therapy and/or hospitalization, life-threatening or fatal infection is exceptional.

CONCLUSION

One-third to one-half the children with febrile neutropenia are at low-risk of serious infection. In the context of clinic trials, they can be safely managed with inpatient or outpatient strategies that maintain close follow-up and reduce the burden of antibiotic therapy. Adoption of these alternative strategies as the standard of care should proceed with caution guided by written protocols.

Evaluation of risk prediction criteria for episodes of febrile neutropenia in children with cancer

PURPOSE

To evaluate the feasibility of risk stratification of children with cancer and febrile neutropenia using a simple set of criteria from data available to the clinician at the time of the patient's presentation.

PATIENTS AND METHODS

This study is a retrospective cohort study of all children with cancer admitted to a single institution with fever and neutropenia (defined as an absolute neutrophil count < 500 cells/mm3) in a 1-year period. Patients were defined a priori as low risk if they were outpatients at the time of presentation with febrile neutropenia, had an anticipated duration of neutropenia less than 7 days, and had no significant comorbidity. All others were considered high risk. Data was analyzed by first admission for each patient and secondarily for all admissions for febrile neutropenia.

RESULTS

There were 188 admissions in 104 patients for febrile neutropenia during the study period. Of these 47% were high risk and 53% were low risk. The duration of fever was not significantly different in the two groups. However, the duration of neutropenia and the length of hospital stay were significantly longer in the high-risk group. The frequency of bacteremia, other documented infection, and serious medical complications was significantly different in the two groups. Overall, the rate of any adverse event was 4% in the low-risk group versus 41% in the high-risk group.

CONCLUSIONS

Simple criteria available to the clinician at the time of evaluation of the child with cancer who has fever and neutropenia allow the selection of a population at low risk for bacteremia or serious medical complication. A prospective study is planned using these risk criteria, evaluating outpatient oral antibiotic therapy in low-risk children with cancer.

Prospective, multicenter evaluation of risk factors associated with invasive bacterial infection in children with cancer, neutropenia, and fever

PURPOSE

To identify clinical and laboratory parameters present at the time of a first evaluation that could help predict which children with cancer, fever, and neutropenia were at high risk or low risk for an invasive bacterial infection.

PATIENTS AND METHODS

Over a 17-month period, all children with cancer, fever, and neutropenia admitted to five hospitals in Santiago, Chile, were enrolled onto a prospective protocol. Associations between admission parameters and risk for invasive bacterial infection were assessed by univariate and logistic regression analyses.

RESULTS

A total of 447 febrile neutropenic episodes occurred in 257 children. Five parameters were statistically independent risk factors for an invasive bacterial infection. Ranked by order of significance, they were as follows: C-reactive protein levels of 90 mg/L or higher (relative risk [RR], 4.2; 95% confidence interval [CI], 3.6 to 4.8); presence of hypotension (RR, 2.7; 95% CI, 2.3 to 3.2); relapse of leukemia as cancer type (RR, 1.8, 95% CI, 1.7 to 2.3); platelet count less than or equal to 50,000/mm(3) (RR, 1.7; 95% CI, 1.4 to 2.2); and recent (< or = 7 days) chemotherapy (RR, 1.3; 95% CI, 1.1 to 1.6). Other previously postulated risk factors (magnitude of fever, monocyte count) were not independent risk factors in this study population.

CONCLUSION

In a large population of children, common clinical and laboratory admission parameters were identified that can help predict the risk for an invasive bacterial infection. These results encourage the possibility of a more selective management strategy for these children.

Oral ciprofloxacin in the management of children with cancer with lower risk febrile neutropenia

BACKGROUND

Recent reports and a previous randomized trial conducted at the authors' institution suggested that a lower risk subset of children with febrile neutropenia under chemotherapy might benefit of an oral antibiotic outpatient approach.

METHODS

The objective of this study was to test the efficacy of oral ciprofloxacin in the treatment of lower risk febrile neutropenia (LRFN) in children treated for malignant diseases. From November 1998 to December 1999, 93 episodes of LRFN in 87 children (median age, 5.5 years; range, 0.9-15.8 years) were included in a prospective randomized controlled single institution trial. Inclusion criteria included fever (> 38 degrees C), severe neutropenia (absolute neutrophil count, < 500/mm(3)), and lower risk features (e.g., absence of severe comorbidity factors, good clinical condition, negative blood cultures, control of local infection, prediction of a period of neutropenia less than 10 days after admission, and compliant parents). After 24 hours of a single intravenous ceftriaxone (100 mg/kg) plus amikacin (15 mg/kg) and completed risk assessment workup, patients were discharged and randomly allocated to two groups. Group A (48 episodes) received ciprofloxacin 20 mg/kg/day orally (p.o.) every 12 hours for 6 days. Group B (45 episodes) received intravenous ceftriaxone plus amikacin for 2 days more followed by cefixime (8 mg/kg/day p.o.) every 24 hours for 4 additional days. Failure was defined as the need of a second hospitalization during the same episode.

RESULTS

Most of the patients (59% in Group A and 52% in Group B) were treated for malignant solid tumors. Fifteen (31%) children in Group A and 15 (33%) in Group B presented with fever of unknown origin (P value was not significant). No significant differences were found in sites of initial infection between both groups. Overall results in this study were excellent. Only one patient with respiratory failure was detected in Group B, who did well with secondary treatment.

CONCLUSIONS

In febrile neutropenic children after anticancer therapy and lower risk features, oral ciprofloxacin for 6 days after 24 hours of intravenous ceftraxione plus amikacin appears to be as efficacious as intravenous ceftriaxone plus amikacin for 2 days more followed by cefixime for 4 additional days. These results contribute to strengthen the concept of LRFN.

Clinical and laboratory features predicting a favorable outcome and allowing early discharge in cancer patients with low-risk febrile neutropenia: a literature review

To value feasibility of early discharge in febrile granulocytopenic patients, 27 original paper published in the last 11 years were analyzed concerning these clinical and therapeutic approaches. A Medline search of English language literature published in the last 11 years (1988-1999) used the key words neutropenia, fever, cancer, home-antibiotic therapy, short course of antibiotic therapy, and early discharge. Twenty-seven original papers fulfilling the study criteria were identified. In these studies, 5208 episodes were evaluated: there were 538 failures with 87 deaths. Features of low-risk patients who developed life-threatening infectious disease were related to general clinical condition, cancer control, bone marrow function, presence of clinical signs of infection, and social features. Careful risk assessment can allow safe recognition of low-risk patients with febrile neutropenia who can be discharged early and can be used to follow outpatient treatment programs to improve patients' quality of life as well as the use of economic resources.

Risk factors assessment in fabrile neutropenia

It is now established that febrile neutropenic cancer patients constitute a heterogeneous population with a variable risk for serious medical complication development. Optimal patient management should take that risk into account by replacing, for instance, the classical, in-hospital administered, broad-spectrum intravenous antibiotics by newer therapeutic approaches including oral and/or outpatient therapeutic strategies for the 'low-risk' patients. The development of such approaches which have been shown safe and feasible, implies the existence of universally accepted, validated and reliable clinical prediction rules for the identification of these low-risk patients. Some prognostic factors predicting the response to the empiric treatment, the development of a bacteremia, and the final outcome of a febrile neutropenic episode have been established (such as duration and profoundness of neutropenia, acute leukemia, administration of chemotherapy for treatment of relapse, high temperature, shock and/or chills, inpatient status at fever onset) and some models combining them have already been proposed, firstly by Talcott and coworkers and more recently by the Multinational Association for Supportive Care in Cancer (MASCC) study section on infections. The sensitivity of these rules as a selection tool for identifying patients at low-risk of complication, however, needs to be improved and we have to assess their clinical usefulness, safety and/or reproducibility better in order to allow a more adequate choice between the therapeutic strategies, to continue to improve patients quality of life and to optimize the cost-effectiveness of the treatments.

Oral administration of cefixime to lower risk febrile neutropenic children with cancer

BACKGROUND

Febrile neutropenia is a heterogeneous condition. Recently, several risk factors have been defined, permitting the definition of a lower risk group of patients who may benefit form less aggressive therapy. The use of an oral antibiotic approach was tested in the current trial.

METHODS

From May 1997 to March 1998, 154 episodes of lower risk febrile neutropenia in 128 children with a mean age of 62 (range, 8-200) months were enrolled in this randomized, single-institution trial. Inclusion criteria were fever (> 38 degrees C), neutropenia (absolute neutrophil count < 500/mm(3)), lower risk features (i.e., absence of severe comorbidity factors, good clinical condition, negative blood cultures, control of local infection, no fever during the last 24 hours), and compliance of parents. After 3 days of ceftriaxone (100 mg/kg/day administered intravenously [i.v.]) every 12 hours plus amikacin (15 mg/kg/day i.v.) every 24 hours for 3 days, all patients were discharged and randomized to be allocated to 2 treatment arms. Group A (n = 74) received ceftriaxone cefixime (8 mg/kg/day administered orally) every 24 hours for 4 days, whereas Group B (n = 80) was treated with ceftriaxone plus amikacin for 7 days. Failure was defined as the need for second hospitalization during the same episode of neutropenia, or fever during the 7 days after discharge.

RESULTS

Most of the patients (49% in Group A and 55% in Group B) had acute leukemia. Fifty-four (72%) children in Group A and 46 (56%) in Group B had fever of unknown origin (P = not significant [NS]). No significant differences were found in the sites of initial infection between the two groups. Overall results were outstanding, with a favorable outcome in 73 of 78 cases (98.6%) in Group A and 78 of 80 cases (97.5%) in Group B (P = NS). Three patients needed a second hospitalization due to failure of the initial therapy: one in Group A and two in Group B. All three did well with secondary treatment.

CONCLUSIONS

In lower risk febrile neutropenic children receiving anticancer therapy, the efficacy of oral cefixime, given for 4 days after 72 hours of intravenous ceftriaxone plus amikacin, was similar to that of 7 days of parenteral ceftriaxone plus amikacin. The oral outpatient therapy approach to the treatment of lower risk febrile neutropenia after chemotherapy is safe and may be cost-saving. This strategy might be adopted as standard therapy in the future.

Plasma IL-8 and IL-6 levels can be used to define a group with low risk of septicaemia among cancer patients with fever and neutropenia

The standard therapy for patients with fever and chemotherapy-related neutropenia is hospitalization and infusion of broad-spectrum antibiotics. Early discharge of a defined group of patients at low risk for septicaemia would be of great advantage for these patients. In this study plasma interleukin-8 (IL-8) and interleukin-6 (IL-6) levels measured at start of fever (n = 72) could define a low-risk group of febrile patients with neutropenia due to chemotherapy. For this purpose we collected and analysed data on 72 fever episodes from 53 patients with chemotherapy-related neutropenia, aged between 1 and 66 years. Of the 72 episodes, 18 were classified as bacteraemia and/or clinical sepsis (sepsis group). The IL-6 and IL-8 plasma concentration were significantly increased in patients with chemotherapy-related neutropenia and fever due to bacteraemia versus fever of non-bacterial origin (P = 0.043 and P = 0.022 respectively). Logistic regression analysis, with sepsis as the outcome variable, revealed significant effects of age combined with either IL-6 or IL-8. Sepsis occurrence was lowest for patients <16 years and highest in patients between 16 and 50 years, and was higher in patients with increased IL-6 (P = 0.032) or IL-8 (P = 0.049). No significant effect of leucocyte count, C-reactive protein, sex or underlying malignancy at presentation was detected. The plasma IL-6 and IL-8 levels were fairly strongly correlated (Pearson r = 0.62). Using a cut-off value with 100% sensitivity, both IL-8 and IL-6 could define a low-risk group of neutropenic patients of 28% (CI 15-40%) at the start of the febrile period. Intervention studies are warranted to confirm this result and to investigate whether an early discharge based on IL-8 or IL-6 measurement is safe, increases the quality of life, and results in cost savings.

Sepsis

OBJECTIVES

To review infection and sepsis in patients with cancer and to provide an overview of controversies and research-based practices of infectious complications and management strategies.

DATA SOURCES

Research studies, review articles, web sites, and consensus documents.

CONCLUSIONS

Traditional assumptions about infection and its optimal management are redefined by research regarding transfusion and catheter-related infections, prophylactic antibiotic administration, use of growth factors, and antimicrobial therapy regimens.

IMPLICATIONS FOR NURSING PRACTICE

Infection is still the most common source of morbidity and mortality among cancer patients. The importance of recognizing high-risk patients, implementing infection prevention practices, and prompt intervention for infection symptoms has been established.

Economic and resource utilization analysis of outpatient management of fever and neutropenia in low-risk pediatric patients with cancer

PURPOSE

To measure resource allocation in outpatient management of fever and neutropenia in low-risk pediatric patients with cancer and its impact on their families.

PATIENTS AND METHODS

A prospective clinical trial was conducted. Eligible patients received a single dose of intravenous (IV) antibiotics and were observed for several hours in clinic. Patients were randomly assigned to continue either IV or oral antibiotics and were seen daily as outpatients. Charges were calculated based on the number of resources used and Medicare/Medicaid reimbursement schedules. A questionnaire was used to measure the impact of outpatient treatment on the family.

RESULTS

Seventy-three episodes of fever and neutropenia were studied. The median duration of treatment was 4 days. Eighty-six percent of the episodes were managed without hospitalization. The median calculated charge was $1840. The median calculated charge for patients receiving oral antibiotics was $1544 and was significantly less than the $2039 median charge for outpatients treated with IV antibiotics. The estimated charge for comparable inpatient treatment was $4503. Nearly all families preferred outpatient care, and few reported a loss of work hours or increased child care expenses.

CONCLUSIONS

Outpatient treatment of low-risk episodes of fever and neutropenia is substantially less costly than inpatient care and is preferred by most families.

Making the transition from hospital to home: caring for the newly diagnosed child with cancer

Current trends in the management of health care show increasing pressure for earlier discharge of children, and their families may or may not be ready to continue the child's care at home. This article provides information that helps the home care provider bridge the transition from hospital care to home care. Care frequently is coordinated by a hospital-based clinical nurse specialist who provides psychosocial support, reinforces teaching, minimizes risks for complications, and performs home infusion therapy, such as antibiotics, chemotherapy, analgesics, total parenteral nutrition, and biologic therapy.

Outpatient parenteral antibiotic therapy for fever and neutropenia

The treatment of fever and neutropenia following chemotherapy lends itself well to outpatient parenteral antimicrobial therapy (OPAT). Patients prefer to be at home rather than hospitalized again. There is a clear cost advantage of outpatient therapy. With a quality program and careful patient selection, OPAT can be provided effectively and safely. The chances of an infection due to resistant bacteria also appear to be reduced. There are an increasing number of studies that support the use of empiric antibiotic therapy for the first fever in neutropenic patients. The choice of antimicrobial, dose, as well as vascular access and infusion devices must be tailored to the individual patient needs and circumstances.

Interleukin 6, but not tumour necrosis factor-alpha, is a good predictor of severe infection in febrile neutropenic and non-neutropenic children with malignancy

OBJECTIVE

Interleukin-6 (IL6), tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) are important mediators of the inflammatory response in human infection. The aim of this study was to determine the relationship between serum levels of IL6, TNF-alpha, IFN-gamma and CRP in febrile children with malignant disease, and relate these levels to aetiology of fever, presence of neutropenia and the effect of untreated malignancy.

METHODS

110 febrile episodes in 70 children with malignant disease were included. Cytokine analyses were performed with sensitive immunoradiometric methods using double monoclonal antibodies.

RESULTS

IL6 had a sensitivity of 74% in detecting sepsis in children with fever and malignant disease. This sensitivity was not influenced by the presence of neutropenia or newly diagnosed malignancy. A positive correlation between IL6 and the CRP levels on the following day was observed (r = .53). TNF-alpha was elevated in 22% of the episodes and mean levels were significantly higher in untreated malignancy but lower in neutropenic patients. IFN-gamma was elevated in 18% of cases and correlated strongly with mean TNF-alpha levels.

CONCLUSIONS

IL6 is a sensitive and early predictor of bacterial infection in both neutropenic and non-neutropenic febrile children with malignancy. It is more sensitive than CRP in detecting sepsis, but the predictive value is too low to allow IL6 levels to influence initial treatment decisions in patients with granulocytopenia. TNF-alpha production seems to be impaired in neutropenic children and serum TNF-alpha cannot be employed as an indicator of bacterial infection.

Low-risk febrile neutropenia in a medical oncology unit

BACKGROUND

Febrile neutropenia occurring in patients receiving chemotherapy for solid tumours or lymphoma is usually of short duration, and therefore may have a better outcome compared to patients with acute leukaemia or patients receiving myeloablative chemotherapy.

AIMS

To review retrospectively the outcomes for febrile neutropenia occurring in patients of the Medical Oncology Unit at our institution, and to identify factors associated with worse outcome, particularly prolonged admission or death.

METHODS

We reviewed 102 episodes of febrile neutropenia occurring in 85 patients treated between 1992 and 1994. Demographic factors, tumour-related factors and clinical aspects of the episodes were correlated with outcome.

RESULTS

The median age was 60 years (range, 18-87), with 56 (55%) episodes occurring in females. Twenty-eight (27%) episodes occurred in patients with lymphoma, with the remaining 74 (73%) occurring in patients with solid tumours. At presentation, the median absolute neutrophil count (ANC) was 0.14 x 10(9)/L with a median duration of significant neutropenia (ANC < 0.5 x 10(9)/L) of three days. The median duration of fever was two days. Twenty-nine (28%) episodes had positive cultures; of these 11 had bacteraemia. Forty-four (43%) episodes were classified as unexplained fevers. The remaining 29 episodes were associated with clinically documented infection but negative cultures. There was a high treatment success rate (81%) with first-line empirical antibiotics. Of 19 treatment failures, 13 were due to the necessity for antibiotic modification; the other six patients died from infection. Factors associated with a worse outcome (including prolonged admission and death) include: diagnosis of lymphoma; increasing number of chemotherapy courses; early onset of neutropenia; pneumonia; severe hypotension; and multiple co-morbidities.

CONCLUSIONS

Febrile neutropenia in adult patients with solid tumours or lymphoma is associated with a relatively good outcome, possibly due to the short duration of neutropenia. A future prospective study to validate the risk factors identified in this study would be useful for defining patients at low risk for the adverse outcomes examined, in whom less intensive management for this condition may be possible.

Outpatient antimicrobial protocol for febrile neutropenia: a nonrandomized prospective trial using ceftriaxone, amikacin, and oral adjuvant agents

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.

Safety of early hospital discharge of selected febrile children and adolescents with cancer with prolonged neutropenia

PROBLEM

The safety of early hospital discharge (i.e., before the absolute neutrophil count [ANC] exceeds 500 cell/mm3) of febrile neutropenic children and adolescents with cancer who had experienced prolonged neutropenia (i.e., for more than 7 days) following admission has not been studied.

METHOD OF STUDY

Three hundred and thirty nine consecutive admissions of children and adolescents with cancer for management of febrile neutropenia were reviewed. Early discharge criteria included absence of fever for 24 hours prior to discharge, sterile blood cultures for 24 hours, evidence of bone marrow recovery defined as a sustained increase in platelet count and ANC or absolute phagocyte count (APC), and control of local infection if present. Children hospitalized with febrile neutropenia who remained neutropenic for more than 7 days were analyzed to assess their outcomes following discharge it they had met criteria for early hospital discharge.

RESULTS

Thirty-three patients in whom neutropenia had persisted for more than 7 days were discharged before attaining an ANC greater than 500/mm3 when they met the early discharge criteria. Only two children (6%) required readmission for recurrent fever, a rate which was not different from that of patients discharged after a more transient episode of neutropenia (2 of 33 vs. 3 of 121, P = 0.3). Both patients who were readmitted had a source of local infection which worsened despite oral antibiotics. Both patients appeared clinically well at the time of readmission and had sterile cultures during their second hospitalization with resolution of local infection.

CONCLUSION

This study confirms that low-risk criteria used to select children with cancer for discharge before complete resolution of neutropenia can be safely applied to those patients whose neutropenia lasted more than 7 days following admission.

Fever in the neutropenic host

Fever in the neutropenic patient following myelosuppressive chemotherapy is a medical emergency. Appropriate antimicrobial therapy can dramatically reduce infection-related morbidity and mortality. This article reviews the rationale and methodology of treatment as well as its applicability to other neutropenic states. The utility of adjunct therapy with granulocyte- stimulating compounds is also discussed.

Opportunistic infections in oncologic patients

Oncologic patients constitute a population whose susceptibility to infections is conditioned by a broad variety of factors. Advances in antineoplastic treatments have resulted in significant prevalence of severe immunosuppression among such patients. Although impairment of more than one distinct effector limb of host defenses occurs in each patient, infections can usually be attributed to a particular deficiency. Major risk factors for infections include granulocytopenia and defects of cell-mediated immunity or of humoral immunity. In the extreme situation of allogeneic bone marrow transplantation, the multitude and the timing of infections can be explained by significant dysfunction of all types of specific immune deficiencies. Treatment of bacterial infections has become more effective with the advent of broad-spectrum antibiotics; however, the dreadful emergence of polyresistant strains may be a serious problem in the near future. Prevention strategies have reduced the risk posed by important pathogens such as CMV or PCP, whereas we still lack reliable treatment against invasive mycoses. The advent of growth factors is a useful adjunct in our armamentarium; in addition to shortening the neutropenic periods after chemotherapy, they may restore qualitative defects of phagocytes. Their exact usefulness and role in managing infections remains to be defined.

A pilot study of outpatient management of febrile neutropenic children with cancer at low risk of bacteremia

Febrile neutropenic children with cancer were eligible for outpatient management with intravenous ceftriaxone therapy if they displayed selected low-risk criteria. Nineteen children were enrolled. All patients had sterile blood cultures, and only one of them was hospitalized because of persistent fever. This pilot study suggests that selected children with febrile neutropenia might be successfully managed without hospitalization.

An approach to the design and implementation of clinical trials of empirical antibiotic therapy in febrile and neutropenic cancer patients

The results of many clinical trials on empirical therapy in febrile, neutropenic cancer patients cannot be readily transferred to the clinical practice, because the methodology is often flawed and definitions, study endpoints and eligibility criteria differ from trial to trial. This article critically reviews some issues related to the design and implementation of randomised clinical trials of empirical antibiotic therapy in cancer patients. Within the definition of phase III clinical trials, two approaches co-exist, based on the trial's specific aims: the "explanatory" approach and the "pragmatic" approach. The usual "explicit" aim of clinical trials of empirical therapy in febrile, neutropenic patients has been that of comparing the "efficacy" of two regimens. However, this term has been more often used with reference to the antibacterial activity of the regimen under study (explanatory aim) than to indicate the practical benefits it draws to the overall patient population treated for fever and neutropenia (pragmatic aim). These two meanings are often taken as perfectly interchangeable, while, conversely, they are completely distinct (though not independent) treatment effects. Most trials conducted in this patient population in recent years are explanatory trials, though not explicitly so, but their results have been widely applied to clinical practice, as they were pragmatic trials. In an explanatory trial the appropriate endpoint is success or failure (defined by clinical and laboratory data) among those patients affected with the specific infection for which the study drug is being given, while in pragmatic trials survival is probably the more appropriate outcome variable, since they are designed to assess the practical benefits that the overall population of febrile and neutropenic patients can obtain from the new empirical treatment. Unfortunately, survival is not a practical study endpoint for the difficulty in assessing the cause of death in this patient population and, especially, for the need for very large sample sizes, which might render the implementation problematic even for large, multicentre groups. Both types of trials need an intention to treat analysis, but this is especially crucial for pragmatic trials, which should not differentiate those cases in which success was obtained through multiple treatment modifications from those who did not require any treatment change. Obviously, this implies that no conclusion should be drawn about the antibacterial activity of the study drugs and that the number of treatment modifications should be taken into account in the interpretation of the results, especially for quality of life and cost evaluations. Information related to fever and signs of infection, age, underlying disease, neutropenia and concomitant administration of other antibiotics are crucial entry criteria that need to be clearly discussed and defined. Finally, the evaluation of toxicity is problematic in this patient population, due to the existence of a number of toxigenic factors, including the underlying disease, the type of infectious complication, the administration of chemotherapy and radiotherapy and the use of parental nutrition. All these effects tend to overlap, thus impairing the investigator's ability to detect specific drug-related side-effects.

Feasibility of outpatient management of fever in cancer patients with low-risk neutropenia: results of a prospective randomized trial

PURPOSE

We recently demonstrated the efficacy of single-agent oral ofloxacin in the management of hospitalized neutropenic febrile patients. Ofloxacin was particularly effective in patients with short duration of neutropenia and fever of undetermined origin. These results prompted us to study the feasibility of outpatient management of neutropenic febrile patients who are otherwise at low risk of morbidity and mortality.

PATIENTS AND METHODS

This multi-institutional, prospective, randomized trial included 182 low-risk neutropenic febrile episodes. After an initial work-up for fever, patients were randomized to receive oral ofloxacin 400 mg immediately and twice daily thereafter in the hospital or as outpatients. Close monitoring and follow-up were carried out in all patients. Those who failed to respond and remained febrile were given parenteral antibiotics. Nonresponding outpatients were admitted to the hospital for parenteral therapy.

RESULTS

One hundred sixty-nine episodes were evaluable. The hospital and outpatient treatment groups had comparable clinical characteristics. Pyrexias of undetermined origin (PUO) comprised 69% of episodes managed in hospital and 73% of episodes treated outside. The success rate with PUO was similar with inpatient and outpatient management. Patients with clinical and microbiologic infections fared less well than those with PUO. Overall, 78% of inpatient and 77% of outpatient fevers resolved with no modification of the initial treatment. Twenty-one percent of patients originally assigned to outside management required hospitalization. Mortality was 2% among inpatients and 4% among outpatients. One early death in a nonhospitalized patient underscores the need for close monitoring and surveillance in these cases.

CONCLUSIONS

Outpatient management of low-risk neutropenic febrile patients with ofloxacin is as effective as inpatient management with the same agent. This approach should be limited to the subset of patients with low-risk factors who are not otherwise on quinolone prophylaxis.

Safety and cost effectiveness of early hospital discharge of lower risk children with cancer admitted for fever and neutropenia

BACKGROUND

Standard treatment for fever during periods of chemotherapy-induced neutropenia includes hospitalization and administration of intravenous antibiotics until the patient is afebrile and no longer neutropenic. This study prospectively evaluates the safety and cost-effectiveness of early discharge of selected low risk children before recovery from neutropenia.

METHODS

We studied 74 children with cancer during 131 consecutive admissions for fever during a period of neutropenia. All patients initially were hospitalized and received broad-spectrum antibiotics. Intravenous antibiotic therapy was discontinued, and the patients promptly were discharged even if they had an absolute neutrophil count (ANC) of less than 500 cells/mm3 as long as they were afebrile, appeared clinically well, had negative cultures, exhibited control of local infection, and showed hematologic evidence of bone marrow recovery.

RESULTS

Intravenous antibiotics were discontinued in 82 cases (63%) before recovery of the ANC to more than 500 cells/mm3, and 78 patients were discharged immediately. None of 70 patients discharged while neutropenic but exhibiting a rising ANC at the time of discharge developed recurrent fever and required readmission. Thirty of these children had an improving localized infection when intravenous antibiotics were discontinued and completed a course of oral antibiotics at home. The estimated mean savings in hospital charges due to early discharge was $5058 per patient.

CONCLUSIONS

Low risk children with cancer who are hospitalized and treated for fever and neutropenia but appear clinically well may have intravenous antibiotics discontinued and be discharged safely irrespective of the ANC, as long as their granulocyte count is rising. This approach shortens hospital stays and results in considerable cost savings.

Factors associated with bacteraemia in febrile, granulocytopenic cancer patients. The International Antimicrobial Therapy Cooperative Group (IATCG) of the European Organization for Research and Treatment of Cancer (EORTC)

The objective of this investigation was to determine factors predictive of bacteraemia at presentation in febrile, granulocytopenic cancer patients in order to estimate the probability of bacteraemia in each patient, and to compare factors associated with a diagnosis of gram-positive or gram-negative bacteraemia. Retrospective analysis of two sets of data (derivation and validation sets) randomly obtained from a large prospective study was conducted in a multicentre study of febrile, granulocytopenic cancer patients admitted for empiric antibacterial therapy. Within the derivation set, prognostic factors (clinical and laboratory data) likely to be associated with a generic diagnosis of bacteraemia and with a specific diagnosis of gram-positive or gram-negative bacteraemia were analysed by means of three backward, stepwise, logistic regression analyses. The predictive probability of bacteraemia was calculated using the logistic equation. The discriminating ability of the model in predicting bacteraemia was evaluated in the derivation and validation sets using receiver-operating characteristic curves. The predictive probability of gram-positive or gram-negative bacteraemia was not calculated. In the derivation set, 157 of 558 episodes (28%) were microbiologically documented bacteraemias. Predicting factors were antifungal prophylaxis, duration of granulocytopenia before fever, platelet count, highest fever, shock and presence and location of initial signs of infection. The variables institution, antibacterial prophylaxis and underlying disease showed borderline associations with bacteraemia. Shock was associated with gram-negative bacteraemia, while signs of infection at catheter site were predictive of gram-positive bacteraemia. Quinolone prophylaxis was negatively associated with gram-negative bacteraemia. When tested in the validation set, the model was poorly predictive, although a small subgroup of episodes (representing only 16% of the total sample size) with low risk of bacteraemia was identified. Factors predictive of bacteraemia can be identified, with discrimination between gram-positive and gram-negative aetiology. Further studies are warranted in order to improve the discriminant ability of the model.