Outpatient therapy for febrile neutropenia: who, when, and how?

Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients

BACKGROUND

Fever occurring in a neutropenic patient remains a common life-threatening complication of cancer chemotherapy. The common practice is to admit the patient to hospital and treat him or her empirically with intravenous broad-spectrum antibiotics. Oral therapy could be an alternative approach for selected patients.

OBJECTIVES

To compare the efficacy of oral antibiotics versus intravenous (IV) antibiotic therapy in febrile neutropenic cancer patients.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1) in The Cochrane Library, MEDLINE (1966 to January week 4, 2013), EMBASE (1980 to 2013 week 4) and LILACS (1982 to 2007). We searched several databases for ongoing trials. We checked the conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) (1995 to 2007), and all references of included studies and major reviews were scanned.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing oral antibiotic(s) to intravenous antibiotic(s) for the treatment of neutropenic cancer patients with fever. The comparison between the two could be started initially (initial oral) or following an initial course of intravenous antibiotic treatment (sequential).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and methodological quality and extracted data. Data concerning mortality, treatment failures and adverse events were extracted from the included studies assuming an 'intention-to-treat' basis for the outcome measures whenever possible. Risk ratios (RR) with 95% confidence intervals (CI) were estimated for dichotomous data. Risk of bias assessment was also made in line with methodology of The Cochrane Collaboration.

MAIN RESULTS

Twenty-two trials (3142 episodes in 2372 patients) were included in the analyses. The mortality rate was similar when comparing oral to intravenous antibiotic treatment (RR 0.95, 95% CI 0.54 to 1.68, 9 trials, 1392 patients, median mortality 0, range 0% to 8.8%). Treatment failure rates were also similar (RR 0.96, 95% CI 0.86 to 1.06, all trials). No significant heterogeneity was shown for all comparisons but adverse events. The effect was stable in a wide range of patients. Quinolones alone or combined with another antibiotic were used with comparable results. Adverse reactions, mostly gastrointestinal, were more common with oral antibiotics.

AUTHORS' CONCLUSIONS

Based on the present data, oral treatment is an acceptable alternative to intravenous antibiotic treatment in febrile neutropenic cancer patients (excluding patients with acute leukaemia) who are haemodynamically stable, without organ failure, and do not have pneumonia, infection of a central line or a severe soft-tissue infection. The wide CI for mortality allows the present use of oral treatment in groups of patients with an expected low risk for mortality, and further research should be aimed at clarifying the definition of low risk patients.

Prediction of outcome in cancer patients with febrile neutropenia: a prospective validation of the Multinational Association for Supportive Care in Cancer risk index in a Chinese population and comparison with the Talcott model and artificial neural network

PURPOSE

We aimed to validate the Multinational Association for Supportive Care in Cancer (MASCC) risk index, and compare it with the Talcott model and artificial neural network (ANN) in predicting the outcome of febrile neutropenia in a Chinese population.

METHODS

We prospectively enrolled adult cancer patients who developed febrile neutropenia after chemotherapy and risk classified them according to MASCC score and Talcott model. ANN models were constructed and temporally validated in prospectively collected cohorts.

RESULTS

From October 2005 to February 2008, 227 consecutive patients were enrolled. Serious medical complications occurred in 22% of patients and 4% died. The positive predictive value of low risk prediction was 86% (95% CI = 81-90%) for MASCC score ≥ 21, 84% (79-89%) for Talcott model, and 85% (78-93%) for the best ANN model. The sensitivity, specificity, negative predictive value, and misclassification rate were 81%, 60%, 52%, and 24%, respectively, for MASCC score ≥ 21; and 50%, 72%, 33%, and 44%, respectively, for Talcott model; and 84%, 60%, 58%, and 22%, respectively, for ANN model. The area under the receiver-operating characteristic curve was 0.808 (95% CI = 0.717-0.899) for MASCC, 0.573 (0.455-0.691) for Talcott, and 0.737 (0.633-0.841) for ANN model. In the low risk group identified by MASCC score ≥ 21 (70% of all patients), 12.5% developed complications and 1.9% died, compared with 43.3%, and 9.0%, respectively, in the high risk group (p < 0.0001).

CONCLUSIONS

The MASCC risk index is prospectively validated in a Chinese population. It demonstrates a better overall performance than the Talcott model and is equivalent to ANN model.

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.

Investigation of an outbreak of gram-negative bacteremia among hematology-oncology outpatients

OBJECTIVE

To identify risk factors associated with an outbreak of gram-negative bacteremia (GNB).

SETTING

A university hospital.

PATIENTS

Hematology-oncology outpatients.

DESIGN

Retrospective case-control study.

RESULTS

Thirty-eight patients developed GNB; 13 patients experienced more than one episode, and eight blood cultures grew more than one gram-negative organism. The most frequently isolated organisms were Stenotrophomonas maltophilia, Klebsiella pneumoniae, Acinetobacter baumannii, and Acinetobacter johnsonii. When the GNB patients (cases) were compared with randomly selected hematology-oncology patients (controls), central venous catheter (CVC) self-care (71% vs 39%; P=.02), and duration of recent hospital stay (median, 15 vs 4 days; P=.01) were identified as risk factors. In a logistic regression model, duration of recent hospital stay was the only risk factor significantly associated with GNB (odds ratio, 1.05; 95% confidence interval, 1.01-1.08; P<.02).

CONCLUSIONS

Hematology-oncology patients providing their own CVC care who have recently been hospitalized for more than 2 weeks may be at increased risk of GNB. CVCs should be protected from possible environmental contamination in hematologyoncology patients. Patients providing their own CVC care should undergo continued rigorous education regarding proper CVC care.