The prevention of febrile neutropenia

PURPOSE OF REVIEW

Febrile neutropenia causes significant morbidity and mortality in patients receiving cytotoxic chemotherapy. Antibiotic and granulocyte colony stimulating factor prophylaxis reduce the incidence of febrile neutropenia but uncertainty remains regarding their role in clinical practice. We review recent literature to clarify the issue.

RECENT FINDINGS

Recent research confirms that prophylactic antibiotics decrease febrile neutropenia and infection-related mortality in acute leukaemia patients and those receiving high dose chemotherapy. Fluoroquinolone prophylaxis also decreases the incidence of febrile neutropenia and all-cause mortality in the first cycle of moderately myelosuppressive chemotherapy for solid tumours. There is no convincing evidence that colonization of individuals with resistant organisms due to antibiotic prophylaxis increases febrile neutropenia or mortality. Granulocyte colony stimulating factor prophylaxis reduces infection-related mortality in patients with greater than 20% risk of febrile neutropenia.

SUMMARY

Antibiotic prophylaxis should be offered to patients receiving chemotherapy for acute leukaemia and high dose chemotherapy for solid tumours. It should also be offered to those receiving moderately myelosuppressive chemotherapy for solid tumours and lymphomas during the first cycle of chemotherapy. Prophylactic granulocyte colony stimulating factor is indicated for patients at greater than 20% risk of febrile neutropenia. Further research is indicated to determine whether combining granulocyte colony stimulating factor and antibiotic prophylaxis causes a further reduction in infection-related mortality.

2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline

PURPOSE

To update the 2000 American Society of Clinical Oncology guideline on the use of hematopoietic colony-stimulating factors (CSF).

UPDATE METHODOLOGY

The Update Committee completed a review and analysis of pertinent data published from 1999 through September 2005. Guided by the 1996 ASCO clinical outcomes criteria, the Update Committee formulated recommendations based on improvements in survival, quality of life, toxicity reduction and cost-effectiveness.

RECOMMENDATIONS

The 2005 Update Committee agreed unanimously that reduction in febrile neutropenia (FN) is an important clinical outcome that justifies the use of CSFs, regardless of impact on other factors, when the risk of FN is approximately 20% and no other equally effective regimen that does not require CSFs is available. Primary prophylaxis is recommended for the prevention of FN in patients who are at high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. CSF use allows a modest to moderate increase in dose-density and/or dose-intensity of chemotherapy regimens. Dose-dense regimens should only be used within an appropriately designed clinical trial or if supported by convincing efficacy data. Prophylactic CSF for patients with diffuse aggressive lymphoma aged 65 years and older treated with curative chemotherapy (CHOP or more aggressive regimens) should be given to reduce the incidence of FN and infections. Current recommendations for the management of patients exposed to lethal doses of total body radiotherapy, but not doses high enough to lead to certain death due to injury to other organs, includes the prompt administration of CSF or pegylated G-CSF.