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Forcano-Queralt E, Lemes-Quintana C, Orozco-Beltrán D. Ambulatory management of low-risk febrile neutropenia in adult oncological patients. Systematic review. Support Care Cancer 2023; 31:665. [PMID: 37921996 PMCID: PMC10624743 DOI: 10.1007/s00520-023-08065-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/22/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE Recent clinical practice guidelines have recommended ambulatory management of febrile neutropenia in patients with low risk of complications. Although some centers have begun developing management protocols for these patients, there appears to be a certain reluctance to implement them in clinical practice. Our aim is to evaluate the strengths and weaknesses of this strategy according to available evidence and to propose new lines of research. METHODS Systematic review using a triple aim approach (efficacy, cost-effectiveness, and quality of life), drawing from literature in MEDLINE (PubMed), Embase, and Cochrane Library databases. The review includes studies that assess ambulatory management for efficacy, cost-efficiency, and quality of life. RESULTS The search yielded 27 articles that met our inclusion criteria. CONCLUSION In conclusion, based on current evidence, ambulatory management of febrile neutropenia is safe, more cost-effective than inpatient care, and capable of improving quality of life in oncological patients with this complication. Ambulatory care seems to be an effective alternative to hospitalization in these patients.
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Affiliation(s)
- Ester Forcano-Queralt
- Gran Canaria Island Maternal-Infant University Hospital Complex, 35016, Las Palmas de Gran Canaria, Spain
| | - Cristina Lemes-Quintana
- Gran Canaria Island Maternal-Infant University Hospital Complex, 35016, Las Palmas de Gran Canaria, Spain
| | - Domingo Orozco-Beltrán
- Clinical Medicine Department, School of Medicine, University Miguel Hernández de Elche, 03550, San Juan de Alicante, Spain.
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Kennedy K, Auret K. Is parenteral chemotherapy safe in rural hospitals? A prospective audit of neutropenic fever in Albany Hospital, a regional West Australian cancer centre. Intern Med J 2016; 47:177-182. [PMID: 27753283 DOI: 10.1111/imj.13301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/11/2016] [Accepted: 10/09/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neutropenic fever is a life-threatening complication of chemotherapy. The widely dispersed population of Australia creates challenges for rural patients in accessing healthcare services. Cancer treatment is particularly, burdensome with patients being forced to relocate to the city for treatment or to endure long and repeated journeys to the city. This study aimed to assess the safety of chemotherapy in a rural centre with a general physician-led model, by analysing neutropenic fever in Albany Hospital, a regional cancer centre in Western Australia. METHODS A prospective audit of patients undergoing parenteral chemotherapy was undertaken from March 2014 to March 2015. Cases of neutropenic fever as a consequence of parenteral chemotherapy were analysed and recorded by the Albany Hospital medical registrar. RESULTS There were 1294 cycles of chemotherapy administered to 192 patients during the study period. There were 19 cases of neutropenic fever in 16 patients, meaning 8.33% of patients undergoing parenteral chemotherapy had their treatment complicated by neutropenic fever (n = 16/192). The incidence of neutropenic fever was 1.47% per cycle of chemotherapy (n = 19/1294). There were no deaths in the study period. As per guidelines, antibiotics were given within 60 min of arrival in 73.68% of cases (n = 14/19). CONCLUSIONS The rate of neutropenic fever observed was similar to rates in other centres worldwide, and the mortality rate was lower than average, with no deaths in the study population. These results provide reassurance with regards to the safe delivery of parenteral chemotherapy in this rural centre with a general physician-led model.
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Affiliation(s)
- K Kennedy
- Royal Perth Hospital, Perth, Western Australia, Australia.,Royal Australasian College of Physicians, Sydney, New South Wales, Australia
| | - K Auret
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
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3
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A comparison of ED and direct admission care of cancer patients with febrile neutropenia. Am J Emerg Med 2015; 33:966-9. [DOI: 10.1016/j.ajem.2015.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 04/10/2015] [Indexed: 11/21/2022] Open
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Pherwani N, Ghayad JM, Holle LM, Karpiuk EL. Outpatient management of febrile neutropenia associated with cancer chemotherapy: Risk stratification and treatment review. Am J Health Syst Pharm 2015; 72:619-31. [DOI: 10.2146/ajhp140194] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Nisha Pherwani
- Oncology, Cardinal Health, Innovative Delivery Solutions, Houston, TX
| | | | - Lisa M. Holle
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
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Fehér C, Rovira M, Soriano A, Esteve J, Martínez JA, Marco F, Carreras E, Martínez C, Fernández-Avilés F, Suárez-Lledó M, Mensa J. Effect of meropenem administration in extended infusion on the clinical outcome of febrile neutropenia: a retrospective observational study. J Antimicrob Chemother 2014; 69:2556-62. [PMID: 24855125 DOI: 10.1093/jac/dku150] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Information on the efficacy of extended meropenem administration in neutropenic patients is scarce. Our objective was to determine whether the administration of meropenem in a 4 h extended infusion (EI) leads to a better clinical outcome in patients with febrile neutropenia than the conventional short infusion (SI). METHODS This was a retrospective observational study. The subjects were neutropenic patients who presented with fever after receiving haematopoietic stem-cell transplantation or induction chemotherapy for acute myeloid leukaemia. The primary endpoint was the success of treatment after 5 days of meropenem therapy, defined as follows: the disappearance of fever leading to a maintained (≥ 24 h) feverless state; the resolution or improvement of the clinical signs and symptoms of infection; the absence of persistent or breakthrough bacteraemia; and no additional antibiotics prescribed because of an unsatisfactory clinical evolution. RESULTS Eighty-eight patients received meropenem (1 g/8 h) in SI and 76 received the same dose in EI. Treatment success on day 5 was superior in the EI group [52/76 (68.4%) versus 36/88 (40.9%); P<0.001]. Meropenem administered in EI was independently associated with success (OR 3.13, 95% CI 1.61-6.10). Fewer additional antibiotics were prescribed in the EI group during the first 5 days of treatment [20/76 (26.3%) versus 44/88 (50.0%); P=0.002]. Using Kaplan-Meier survival analysis a more prompt defervescence and a faster decrease in C-reactive protein concentration were observed in the EI group (P=0.021 and P=0.037, respectively). There were no significant differences in the length of hospital stay and in the mortality rate. CONCLUSIONS Meropenem administration in EI results in a better clinical outcome for febrile neutropenia episodes, with fewer additional antibiotics needed.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain
| | - Montserrat Rovira
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain University of Barcelona, Barcelona, Spain
| | - Jordi Esteve
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José Antonio Martínez
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesc Marco
- Microbiology Service, Hospital Clínic, Barcelona, Spain Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-University of Barcelona, Barcelona, Spain
| | - Enric Carreras
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Carmen Martínez
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesc Fernández-Avilés
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - María Suárez-Lledó
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Abstract
Neutropenia remains the predominant predisposing factor for infection in most cancer patients. Bacterial and fungal infections are common in this setting. Not all neutropenic patients have the same risk of developing severe infection or serious medical complications. Although all patients with neutropenia and fever should receive prompt, empiric antibiotic therapy, low-risk patients can be effectively managed without hospitalization-often with the administration of oral antibiotics. Other patients need hospital-based therapy. The emergence of resistant microorganisms has become a significant problem in neutropenic patients. Frequent epidemiologic surveys to detect the emergence of resistant organisms are recommended. Antibiotic stewardship and Infection Control Programs are important tools in combating resistant organisms.
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Affiliation(s)
- Kenneth V I Rolston
- Department of Infectious Diseases, Infection Control, and Employee Health, V.T. MD Anderson Cancer Center, 1515 Holcombe BLVD, Houston, TX, 77030, USA,
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Abstract
The range of opportunist pathogens in cancer and transplant patients continues to increase. New treatment modalities and forms of immunosuppression following transplantation have improved survival from the underlying disease but can lead to prolonged immunosuppression and increased risk of infection. NICE guidelines for the management of neutropenic sepsis are now available but have aroused some controversy, particularly over the recommendation for quinolone prophylaxis in high-risk patient groups. In addition to neutropenia, long-term defects in cell-mediated immunity are exposing patients to risk of chronic, viral, protozoal and fungal infection. Advances in diagnostic techniques have the potential to improve management and limit unnecessary empirical treatment, allowing a move towards a diagnosis-driven strategy. However, interpreting the clinical validity and utility of some of these assays can be difficult, particularly for low-prevalence infection where the positive predictive value of any diagnostic test is likely to be low and prompt empirical antibacterial therapy is still indicated in neutropenic patients.
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Affiliation(s)
- Rosemary A Barnes
- is Professor/Honorary Consultant, Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. Competing interests: RAB has served on advisory boards, received sponsorship and travel expenses to attend meetings and received honoraria for lectures/symposia from Merck, Sharp and Dohme, Astellas, Gilead Sciences and Pfizer. In addition, she has received educational grants, scientific fellowship awards and independent researcher grants from Gilead Sciences and Pfizer. She is a member of the European Aspergillus PCR Initiative Working Group of the International Society for Human and Animal Mycology and a board member of the foundation European Aspergillus PCR initiative. She is a member of the Steering Group of the NISCHR funded Microbiology and Translational Infection Research Group. She served on the clinical guideline development group for the NICE Neutropenic sepsis guideline
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Wiernik PH, Goldman JM, Dutcher JP, Kyle RA. Evaluation and Management of Bacterial and Fungal Infections Occurring in Patients with a Hematological Malignancy: A 2011 Update. NEOPLASTIC DISEASES OF THE BLOOD 2013. [PMCID: PMC7120157 DOI: 10.1007/978-1-4614-3764-2_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with a hematological malignancy are a heterogeneous patient population who are afflicted with diseases that range from rapidly fatal acute leukemia to indolent lymphoma or chronic leukemia. Treatment options for these patients range from observation to hematopoietic stem cell transplantation (HSCT), but all patients are more susceptible to infection. The problem of infection is dynamic with continued shifts in pathogenic organisms and microbial susceptibilities, new treatment regimens that further diminish immune function, and patients receiving treatment who are now older and frailer. The classic patterns of immunodeficiency for patients with a hematological malignancy include: periods of profound neutropenia, increased iatrogenic risks (i.e., central vascular catheters), and cellular immune suppression that affects HSCT recipients, patients with lymphoid malignancies, and those receiving treatment with corticosteroids or agents like alemtuzumab [1–4]. Recent advances in antimicrobial drug development, new technology, clinical trial results, and further clinical experience have enhanced the database on which to make infection prophylaxis and treatment decisions. However, the practicing clinician must remember that the majority of basic infection management principles for patients who are neutropenic remain unchanged.
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Affiliation(s)
- Peter H. Wiernik
- Beth Israel Hospital, Cancer Center, St. Lukes-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - John M. Goldman
- , Department of Hematology, Imperial College of London, Du Cane Road 150, London, W12 0NN United Kingdom
| | - Janice P. Dutcher
- Continuum Cancer Centers, Department of Medicine, St. Luke's-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - Robert A. Kyle
- , Division of Hematology, Mayo Clinic, First Street SW. 200, Rochester, 55905 Minnesota USA
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Horasan ES, Ersoz G, Tombak A, Tiftik N, Kaya A. Bloodstream infections and mortality-related factors in febrile neutropenic cancer patients. Med Sci Monit 2011; 17:CR304-9. [PMID: 21525814 PMCID: PMC3539578 DOI: 10.12659/msm.881773] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background We performed a prospective observational cohort study to evaluate the causative bacteria and to identify risk factors for mortality in febrile neutropenic (FN) patients with blood stream infection (BSI). Material/Methods We conducted a prospective data collection on all patients with bacteremia or fungemia. The patients were assigned into low-risk and high-risk groups in accordance with the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index. Results Throughout the study period, the patients developed 420 FN episodes. Out of 420 episodes, only 90 (21.4%) were found to have bloodstream infection. The mean age of the patients was 45.6±18.4 years and 55.6% of the patients were male. A total of 98 isolates were recovered from the cases of BSI. Coagulase-negative Staphylococcus spp (CoNS) were the most common isolates overall (33.7%). There was a significant increase in the rate of gram-negative bacteria throughout the study period (p=0.028). Overall mortality was 33%. Multivariate analyses showed that MASCC risk scores (p=0.0001, OR=15.1, CI%95 4.5–50.7), ICU wards (p=0.0002, OR= 8.6, Cl%95 1.101–68,157) and CoNS (p=0.004, OR=12.12, CI%95 2.3–64.7) were independent risk factors associated with mortality. BSI due to CoNS was associated with lower mortality; however, MASCC high risk score and ICU stay were associated with higher mortality. Conclusions The MASCC risk-index score and emergence of CoNS in positive blood cultures are valuable tools in the management of FN.
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Affiliation(s)
- Elif Sahin Horasan
- Department of Clinical Microbiology and Infectious Diseases, Mersin University, Faculty of Medicine, Mersin, Turkey.
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Lee DG, Kim SH, Kim SY, Kim CJ, Park WB, Song YG, Choi JH. Evidence-based guidelines for empirical therapy of neutropenic fever in Korea. Korean J Intern Med 2011; 26:220-52. [PMID: 21716917 PMCID: PMC3110859 DOI: 10.3904/kjim.2011.26.2.220] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers.
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Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.
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Lee DG, Kim SH, Kim SY, Kim CJ, Min CK, Park WB, Park YJ, Song YG, Jang JS, Jang JH, Jin JY, Choi JH. Evidence-based Guidelines for Empirical Therapy of Neutropenic Fever in Korea. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.4.285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Young Kim
- Department of Family Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Chung-Jong Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joung-Soon Jang
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jun Ho Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Youl Jin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Maubon D, Hamidfar-Roy R, Courby S, Vesin A, Maurin M, Pavese P, Ravanel N, Bulabois CE, Brion JP, Pelloux H, Timsit JF. Therapeutic impact and diagnostic performance of multiplex PCR in patients with malignancies and suspected sepsis. J Infect 2010; 61:335-42. [PMID: 20637801 DOI: 10.1016/j.jinf.2010.07.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 07/07/2010] [Accepted: 07/08/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVES New molecular methods allow rapid pathogen detection in patients with sepsis, but their impact on treatment decisions remains to be established. We evaluated the therapeutic usefulness of multiplex PCR testing in patients with cancer and sepsis. METHODS 110 patients with cancer and sepsis were included prospectively and underwent LightCycler® SeptiFast (LC-SF) multiplex PCR testing in addition to standard tests. Two independent panels of experts assessed the diagnosis in each patient based on medical record data; only one panel had the LC-SF results. The final diagnosis established by a third panel was the reference standard. RESULTS The final diagnosis was documented sepsis in 50 patients (55 microorganisms), undocumented sepsis in 54, and non-infectious disease in 6. LC-SF detected 17/32 pathogens recovered from blood cultures (BC) and 11/23 pathogens not recovered from BC; 12 microorganisms were detected neither by BC nor by LC-SF. LC-SF produced false-positive results in 10 cases. The LC-SF results would have significantly improved treatment in 11 (10%) patients and prompted immediate antimicrobial therapy not given initially in 3 patients. CONCLUSIONS In cancer patients with suspected sepsis, LC-SF detected 11/55 (20%) true pathogens not recovered from BCs and would have improved the initial management in 11/110 (10%) patients.
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Affiliation(s)
- Danièle Maubon
- Infectious Agent Department, Parasitology-Mycology Laboratory, Albert Michallon Teaching Hospital, 38043 Grenoble Cedex 9, France.
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Kalin M. Infectious Complications in Association with Cytoreductive Chemotherapy for Malignant Diseases. Scandinavian Journal of Clinical and Laboratory Investigation 2009. [DOI: 10.1080/00855910310002187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Elting LS, Lu C, Escalante CP, Giordano SH, Trent JC, Cooksley C, Avritscher EBC, Shih YCT, Ensor J, Bekele BN, Gralla RJ, Talcott JA, Rolston K. Outcomes and cost of outpatient or inpatient management of 712 patients with febrile neutropenia. J Clin Oncol 2008; 26:606-11. [PMID: 18235119 DOI: 10.1200/jco.2007.13.8222] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We retrospectively compared the outcomes and costs of outpatient and inpatient management of low-risk outpatients who presented to an emergency department with febrile neutropenia (FN). PATIENTS AND METHODS A single episode of FN was randomly chosen from each of 712 consecutive, low-risk solid tumor outpatients who had been treated prospectively on a clinical pathway (1997-2003). Their medical records were reviewed retrospectively for overall success (resolution of all signs and symptoms of infection without modification of antibiotics, major medical complications, or intensive care unit admission) and nine secondary outcomes. Outcomes were assessed by physician investigators who were blinded to management strategy. Outcomes and costs (payer's perspective) in 529 low-risk outpatients were compared with 123 low-risk patients who were psychosocially ineligible for outpatient management (no access to caregiver, telephone, or transportation; residence > 30 minutes from treating center; poor compliance with previous outpatient therapy) using univariate statistical tests. RESULTS Overall success was 80% among low-risk outpatients and 79% among low-risk inpatients. Response to initial antibiotics was 81% among outpatients and 80% among inpatients (P = .94); 21% of those initially treated as outpatients subsequently required hospitalization. All patients ultimately responded to antibiotics; there were no deaths. Serious complications were rare (1%) and equally frequent between the groups. The mean cost of therapy among inpatients was double that of outpatients ($15,231 v $7,772; P < .001). CONCLUSION Outpatient management of low-risk patients with FN is as safe and effective as inpatient management of low-risk patients and is significantly less costly.
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Affiliation(s)
- Linda S Elting
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd (Unit 447), Houston, TX 77030, USA.
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Emergence of MRSA in positive blood cultures from patients with febrile neutropenia--a cause for concern. Support Care Cancer 2008; 16:1085-8. [PMID: 18274787 DOI: 10.1007/s00520-007-0398-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 12/19/2007] [Indexed: 01/05/2023]
Abstract
GOALS OF WORK Febrile neutropenia (FN) causes considerable morbidity in patients on cytotoxic chemotherapy. Recently, there has been a trend towards fewer Gram-negative and more Gram-positive infections with increasing antibiotic resistance. To assess these patterns, data from a supra-regional cancer centre in Ireland were reviewed. PATIENTS AND METHODS A 5-year review of all positive blood cultures in patients undergoing anti-cancer chemotherapy was carried out. MAIN RESULTS Eight hundred and ninety-four patients were reviewed. The mean incidence of FN was 64.2 cases per year. Eight hundred and forty-six blood culture specimens were taken and 173 (20.4%) were culture positive. The isolated organisms were Gram positive (71.1%), Gram negative (27.8%) and fungal (1.1%). Of the Gram-positive organisms, 75.6% were staphylococci. Of these, 67.8% were coagulase-negative staphylococci and 30.1% were Staphylococci aureus. Amongst the S. aureus, 89.3% were methicillin-resistant (MRSA). Vancomycin-resistant enterococci were not identified as a cause of positive blood cultures. CONCLUSIONS Amongst patients with cancer who develop FN in our hospital, Gram-positive bacteria account for the largest proportion. The high proportion of MRSA as a cause of positive blood cultures is of concern.
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Laoprasopwattana K, Pruekprasert P, Laosombat V, Wongchanchailert M. Clinical outcome of febrile neutropenia in children with cancer using ceftazidime and aminoglycosides. Pediatr Hematol Oncol 2007; 24:595-606. [PMID: 18092250 DOI: 10.1080/08880010701703636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
To determine treatment outcome using ceftazidime-aminoglycosides in febrile neutropenic children with cancer, the authors conducted a prospective cohort study in 216 episodes. Early and complete responses to antibiotics were 108/216 (50.0%) and 133/216 (61.6%) episodes, respectively. Death, a modification of antibiotic(s), and resistance to ceftazidime were 2/118 (1.7%), 73/216 (33.8%), and 4/216 (1.9%) episodes, respectively. Primary bacteremia and emerging bacteremia during treatment were 20/216 (9.3%) and 5/216 (2.3%) episodes. Ceftazidime-aminoglycosides was found to be a reasonable initial treatment of febrile neutropenia in the authors' institution. Imipenem is considered in patients who have clinical sepsis and who fail to respond to initial treatment.
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Antoniadou A, Giamarellou H. Fever of Unknown Origin in Febrile Leukopenia. Infect Dis Clin North Am 2007; 21:1055-90, x. [DOI: 10.1016/j.idc.2007.08.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW The management of febrile neutropenia has evolved significantly with the development of risk stratification and recognition of the efficacy of oral antibiotics in low-risk patients. There remains uncertainty concerning the need for hospitalization and role of early hospital discharge. We review recent evidence in this field and identify outstanding issues for future research. RECENT FINDINGS Studies have confirmed the utility of the MASCC risk index. Preliminary findings suggest that early hospital discharge is feasible in low-risk patients with solid tumours and lymphomas, at least in specialist centres. Median hospital stays may be reduced to 48 h with no increase in serious medical complications. Readmission rates remain low. SUMMARY All patients with febrile neutropenia should undergo risk stratification on admission, and low-risk patients should be considered eligible for combination oral antibiotics from the outset. Those patients who show signs of fever resolution and subjective improvement are eligible for early discharge. More research is required with regard to patients with haematological malignancies and/or receiving prophylactic antibiotics, and in the development of factors predictive of successful early discharge. Further data are required regarding whether strategies involving early discharge can be safely implemented at centres outside those which have pioneered these approaches.
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Affiliation(s)
- Helen Innes
- Clatterbridge Centre for Oncology, Bebington, Wirral, Merseyside, UK.
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Batlle M, Lloveras N. Manejo del paciente con neutropenia de bajo riesgo y fiebre. Enferm Infecc Microbiol Clin 2005; 23 Suppl 5:30-4. [PMID: 16857154 DOI: 10.1157/13091244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
For years the classical approach to febrile episodes in patients with chemotherapy-induced neutropenia consisted of hospital admission and intravenous administration of broad-spectrum antibiotics. However, since the end of the 1980s, it has been known that not all episodes of neutropenia carry the same risk of developing complications. These low risk febrile patients with neutropenia, that is, those without a clear focus of infection, without criteria for severe sepsis, and with an expected duration of neutropenia of less than 7-10 days, could benefit from outpatient oral antibiotic therapy or, failing this, from intravenous administration through a perfusion pump in the home. The present study analyzes the current situation of the new treatment modalities that aim to improve patients' quality of life and to optimize healthcare resources and costs.
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Affiliation(s)
- Montserrat Batlle
- Servicio de Hematología Clínica, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Badalona, Barcelona, España.
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20
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Sanz MA, Bermúdez A, Rovira M, Besalduch J, Pascual MJ, Nocea G, Sanz-Rodríguez C. Imipenem/cilastatin versus piperacillin/tazobactam plus amikacin for empirical therapy in febrile neutropenic patients: results of the COSTINE study. Curr Med Res Opin 2005; 21:645-55. [PMID: 15969864 DOI: 10.1185/030079905x43631] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Combinations of beta-lactams plus aminoglycosides have become standard therapy for suspected infections in patients with profound neutropenia. However, it is not clear whether such combinations are advantageous over therapy with a broad-spectrum antibiotic. OBJECTIVE To assess the clinical effectiveness and the cost-effectiveness ratio of empirical therapy of febrile neutropenia with imipenem/cilastatin (I/C) versus piperacillin/tazobactam plus amikacin (P/T+A). RESEARCH DESIGN AND METHODS Prospective, multicenter observational study with 2 matched parallel cohorts treated with I/C (500 mg/6 h iv) or P/T+A (P/T: 4 g/6 h iv; A: 20 mg/kg/day iv). MAIN OUTCOME MEASURES Therapeutic success was defined as the resolution of fever following > or = 7 days of unchanged antibiotic treatment. An economic comparison was conducted focusing on the daily treatment costs, and the management of its toxicity. RESULTS There were 343 eligible patients (180 I/C, 163 P/T+A), of whom 290 were evaluable for the primary clinical effectiveness analysis. Follow-up information beyond 7 days of study inclusion was only available for 52% of all evaluable patients. Treatment success was observed in 42% of I/C patients compared with 31% of P/T+A patients (95% CI: -0.01, 21.4). The incidence of drug-related adverse experiences was 13% for I/C and 6% for P/T+A, with no differences in moderate or severe adverse experiences nor in those causing discontinuation of antibiotic therapy. Treatment costs were 189.55 euros (95% CI: 127.46-251.46) lower per episode of febrile neutropenia for patients treated with I/C. CONCLUSIONS The clinical effectiveness of I/C was similar to that of P/T+A. In both treatment groups toxicity was low and did not limit antibiotic therapy. Resource consumption was lower with I/C.
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Affiliation(s)
- Miguel A Sanz
- Servicio de Hematología, Hospital Universitario La Fe, Valencia, Spain
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21
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Christakis G, Perlorentzou S, Aslanidou M, Megalakaki A, Velegraki A. Fatal Blastoschizomyces capitatus sepsis in a neutropenic patient with acute myeloid leukemia: first documented case from Greece. Mycoses 2005; 48:216-20. [PMID: 15842341 DOI: 10.1111/j.1439-0507.2005.01098.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Blastoschizomyces capitatus (formerly known as Geotrichum capitatum and Trichosporon capitatum) is a rare, yet an emerging, cause of invasive infections in immunosuppressed patients. Profound and prolonged neutropenia is the crucial predisposing factor for this yeast infection. Blastoschizomyces capitatus was isolated from peripheral blood cultures of a profoundly neutropenic patient with acute myeloid leukemia (M2 FAB). Despite administration of antifungal chemotherapy with liposomal amphotericin B at 4.5 mg kg(-1) daily, the patient succumbed 4 days after initiation of treatment. Infections attributed to B. capitatus have generally a poor prognosis, although the yeast shows in vitro susceptibility to antifungal agents. Low flucytosine, caspofungin acetate, voriconazole and amphotericin B minimum inhibitory concentration values were also recorded with our isolate. The clinical relevance of the in vitro susceptibility testing against the isolate and the current antifungal chemotherapy regimens against B. capitatus systemic infections are discussed.
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22
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Sipsas NV, Bodey GP, Kontoyiannis DP. Perspectives for the management of febrile neutropenic patients with cancer in the 21st century. Cancer 2005; 103:1103-13. [PMID: 15666328 DOI: 10.1002/cncr.20890] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Over the past several decades, there has been substantial progress in the management of patients with febrile neutropenia. However, the ever-changing patterns of infection, ecology, and antibiotic-resistance trends do not allow the development of treatment guidelines that could be applied universally. Hence, the institution's predominant pathogens and resistance patterns should guide the empirical choice of antimicrobials. Prompt initiation of antimicrobial therapy remains the gold standard. Monotherapy with the newer broad-spectrum antimicrobials has tended to replace the classic combination therapy. Empirical administration of glycopeptides, such as vancomycin, without documentation of a gram-positive infection is not favored. The development of risk-stratification models has allowed for identification of low-risk patients with additional treatment options, such as early discharge and exclusively outpatient treatment with oral antimicrobials. The initiation of empirical antifungal therapy in persistently febrile neutropenic patients has become common practice, especially recently, since the introduction of new, effective, less toxic antifungal drugs. It is hoped that the development of new nonculture-based diagnostic methods will allow for the early detection of invasive fungal infections and, thus, the replacement of empirical antifungal therapy with pathogen-specific, preemptive therapy.
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Affiliation(s)
- Nikolaos V Sipsas
- Infectious Diseases Unit, Pathophysiology Department, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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23
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Vento S, Cainelli F. Infections in patients with cancer undergoing chemotherapy: aetiology, prevention, and treatment. Lancet Oncol 2003; 4:595-604. [PMID: 14554236 DOI: 10.1016/s1470-2045(03)01218-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with cancer who are undergoing chemotherapy are highly susceptible, especially if neutropenic, to almost any type of bacterial or fungal infection. These infections cause substantial morbidity and mortality. Prophylactic use of antibiotics should be avoided, however, since this practice is associated with a risk of emergence of resistant bacteria and it does not lower the risk of death. However, chemoprophylaxis has a role for candidal fungal infections. Because infection in a neutropenic host can be rapidly fatal if not treated, the empirical administration of broad-spectrum intravenous antibiotics is generally indicated for these patients, and the local frequencies, susceptibility, and resistance patterns of various pathogens must be taken into account. Once therapy has been initiated, changes in antibiotic regimens during the first 5 days are useless unless the patient's clinical condition deteriorates substantially. The treatment of invasive fungal infections is particularly difficult. Many unsolved questions remain, and studies are proposed here that may shed light on these issues.
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Affiliation(s)
- Sandro Vento
- Section of Infectious Diseases, Department of Pathology, University of Verona, Italy.
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24
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Innes HE, Smith DB, O'Reilly SM, Clark PI, Kelly V, Marshall E. Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study. Br J Cancer 2003; 89:43-9. [PMID: 12838298 PMCID: PMC2394220 DOI: 10.1038/sj.bjc.6600993] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Neutropenic sepsis remains a potentially life-threatening complication of anticancer chemotherapy. However, it is possible to identify patients who are at low risk for serious complications and for whom less-intensive, more-convenient treatment may be appropriate. The aim of this study was to assess the efficacy and safety of oral antibiotics in conjunction with early hospital discharge in comparison with standard in-patient intravenous antibiotics in patients with low-risk neutropenic fever. In all, 126 episodes of low-risk neutropenic fever occurred in 102 patients. Patients were randomised to receive either: an oral regimen of ciprofloxacin (750 mg 12 hourly) plus amoxicillin-clavulanate (675 mg 8 hourly) for a total of 5 days, or a standard intravenous regimen of gentamicin and tazocin (piperacillin/tazobactam) until hospital discharge. Patients randomised to oral antibiotics were eligible for discharge following 24 h of hospitalisation, if clinically stable and symptomatically improved. The efficacy of the two arms was similar: initial treatment was successful without antibiotic modification in 90% of episodes in the intravenous arm and 84.8% of episodes in the oral arm, P=0.55, absolute difference between the groups 5.2%; 95% confidence interval (CI) for the difference -7 to 17.3%. Only one episode in the oral arm was associated with significant clinical deterioration: this occurred within the initial in-patient assessment period. The median in-patient stay was 4 days in the intravenous arm (range 2-8) and 2 days in the oral arm (range 1-16 days), P&<0.0005. The reduction in hospital stay led to significant cost-savings in the oral arm. In conclusion, this study suggests that oral antibiotics in conjunction with early hospital discharge for patients who remain stable after a 24 h period of in-patient monitoring offers a feasible and cost-effective alternative to conventional management of low-risk neutropenic fever.
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Affiliation(s)
- H E Innes
- Clatterbridge Centre for Oncology, Bebington, Wirral, Merseyside, UK.
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25
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Goff DA. Cost effective approaches to antimicrobial use in oncology patients. Curr Opin Infect Dis 2002; 15:565-8. [PMID: 12821831 DOI: 10.1097/00001432-200212000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In the current era of cost containment, the management of the oncology patient who presents with neutropenia and fever remains a challenge. This article will review which measures of cost are helpful in determining cost effective antibiotic use in patients with febrile neutropenia. RECENT FINDINGS The majority of direct medical costs associated with treating febrile neutropenic patients are room and board costs. The most recent cost analysis reports a mean cost/day of US$1598. SUMMARY Over the past two decades, infection-related mortality rates have decreased from 50% to rates as low as 10%. In contrast to the numerous studies comparing clinical outcomes of patients receiving different antimicrobial regimens for febrile neutropenia, the recent literature revealed limited studies that evaluate economic data. Typically, new antibiotic regimens show equal efficacy to the standard regimens but are often more expensive. If efficacy rates and safety are the same for an antibiotic, the cost is often used to select the product.
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Affiliation(s)
- Debra A Goff
- College of Pharmacy, The Ohio State University Medical Center, Columbus, Ohio 43210, USA.
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Donowitz GR, Maki DG, Crnich CJ, Pappas PG, Rolston KV. Infections in the neutropenic patient--new views of an old problem. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2002:113-39. [PMID: 11722981 DOI: 10.1182/asheducation-2001.1.113] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Infection in the neutropenic patient has remained a major clinical challenge for over three decades. While diagnostic and therapeutic interventions have improved greatly during this period, increases in the number of patients with neutropenia, changes in the etiologic agents involved, and growing antibiotic resistance have continued to be problematic. The evolving etiology of infections in this patient population is reviewed by Dr. Donowitz. Presently accepted antibiotic regimens and practices are discussed, along with ongoing controversies. In Section II, Drs. Maki and Crnich discuss line-related infection, which is a major infectious source in the neutropenic. Defining true line-related bloodstream infection remains a challenge despite the fact that various methods to do so exist. Means of prevention of line related infection, diagnosis, and therapy are reviewed. Fungal infection continues to perplex the infectious disease clinician and hematologist/oncologist. Diagnosis is difficult, and many fungal infections will lead to increased mortality even with rapid diagnosis and therapy. In Section III, Dr. Pappas reviews the major fungal etiologies of infection in the neutropenic patient and the new anti-fungals that are available to treat them. Finally, Dr. Rolston reviews the possibility of outpatient management of neutropenic fever. Recognizing that neutropenics represent a heterogeneous group of patients, identification of who can be treated as an outpatient and with what antibiotics are discussed.
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Affiliation(s)
- G R Donowitz
- University of Virginia Health System, Charlottesville 22908-1343, USA
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27
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Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, Feld R, Pizzo PA, Rolston KVI, Shenep JL, Young LS. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002; 34:730-51. [PMID: 11850858 DOI: 10.1086/339215] [Citation(s) in RCA: 1238] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2001] [Indexed: 01/09/2023] Open
Affiliation(s)
- Walter T Hughes
- St. Jude Children's Research Hospital, Memphis, TN, 38105, USA.
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