Management Of Low-risk Febrile Neutropenia Research Articles

Efficacy of Levofloxacin Versus Amoxicillin/Clavulanate and Ciprofloxacin in the Outpatient Management of Low-Risk Febrile Neutropenia in Children with Cancer; A Randomised Control Study

Background and Aims Outpatient management of low-risk fever and neutropenia should be implemented if close monitoring is accessible and patient compliance is feasible. the use of Amoxicillin/ Clavulanate plus ciprofloxacin, Levofloxacin, and Moxifloxacin for the treatment of low-risk febrile neutropenia. There are not enough studies assessing the tolerance, safety, and efficacy of these agents in children. In this study, we aimed to assess the efficacy and safety of single-agent Levofloxacin versus the Augmentin /ciprofloxacin regimen used in our institute. Methods This is a randomized prospective interventional 2 arm study of low-risk febrile neutropenia patients presenting to the emergency department at the National Cancer Institute, Cairo University starting from December 2021 to July 2022.Eligible patients were children<18 years with haematological malignancies or haemopoietic and Low-risk febrile neutropenia without aetiological diagnosis. Lottery method was used to randomly enrol patients (1:1) to both arms. Patients were randomized to double agent ciprofloxacin and amoxicillin-clavulanic acid in comparison to single-agent levofloxacin. Follow up of the outpatient cases at; Day 1: Start oral antibiotics, obtain guardians contacts, and assure compliance, Day 3: Follow up the patient clinically and follow up count, and Day 7: Resolution of infection and stopping of antibiotics regardless of neutropenia. Primary outcomes included Safe marrow recovery and improvement of fever in all eligible patients. Drug-related side effects encountered in both arms of the study were reported. Results A preliminary analysis of the first 120 patients (60 in each group) was done. 100% of patients achieved marrow recovery in both arms by D7. Fever subsided in 100% on the Levofloxacin arm compared to 60% in the group receiving Augmentin/Ciprofloxacin. only one patient on the double agent arm was upgraded to HR and admitted to the inpatient. Levofloxacin was tolerable in all patients with no significant side effects apart from insomnia reported by the parents in 1 patient, while patients in the double agent arm; 4 had diarrhoea, 2 nausea and 2 complained of bad drug taste. Conclusions Levofloxacin has better efficacy and can be administered safely in children with low-risk FN, however close follow-up for long-term side effects and monitoring of possible emerging bacterial resistance is warranted.

Home-based care of low-risk febrile neutropenia in children—an implementation study in a tertiary paediatric hospital

Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact. This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety. Over 18months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned. This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.

Emergency Ambulatory Management of Low-Risk Febrile Neutropenia: Multinational Association for Supportive Care in Cancer Fits-Real-World Experience From a UK Cancer Center.

Emergency patient presentations with febrile neutropenia are a heterogeneous group. A small minority of these patients proceed to develop significant medical complications. Risk stratification using scores, such as the Multinational Association for Supportive Care in Cancer score, have been advocated to identify patients who are at low risk of adverse outcome suitable for treatment on an ambulatory care pathway. We sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion. Patients presenting as an emergency with low-risk febrile neutropenia managed in an ambulatory setting between January 2017 and February 2019 at a tertiary cancer hospital in England were prospectively studied. Patients with a fever >38.0°C and an absolute neutrophil count <1.0 × 109/L were included. All patients with a Multinational Association for Supportive Care in Cancer score ≥21 and a National Early Warning Score ≤3 were potentially eligible for the pathway. Complications were classified as serious if the patient developed persistent hypotension, respiratory failure, intensive care unit admission, altered mental status, disseminated intravascular coagulation, renal failure requiring renal replacement therapy, electrocardiogram changes requiring antidysrhythmic treatment, and 30-day mortality. One hundred patients with low-risk febrile neutropenia consecutively managed in an emergency ambulatory fashion were prospectively analyzed. Eighty-one patients were female and the median age was 51 y (range 17-79 y). No patients developed serious complications. Eight (8% [95% confidence interval 4.1-15.0%]) patients had a 7-day readmission. Outpatient ambulatory care for emergency patients with low-risk febrile neutropenia can be delivered in a safe and effective fashion. Collaboration between acute care physicians and oncologists is required to develop local models based on national guidelines to facilitate individualised care for emergency oncology patients.

Comparison of the MASCC and CISNE scores for identifying low-risk neutropenic fever patients: analysis of data from three emergency departments of cancer centers in three continents.

Patients with febrile neutropenia are a heterogeneous group with a minority developing serious medical complications. Outpatient management of low-risk febrile neutropenia has been shown to be safe and cost-effective. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score and Clinical Index of Stable Febrile Neutropenia (CISNE), have been developed and validated to identify low-risk patients. We aimed to compare the performance of these two scores in identifying low-risk febrile neutropenic patients. We performed a pooled analysis of patients presenting with febrile neutropenia to three tertiary cancer emergency centers in the USA, UK, and South Korea in 2015. The primary outcome measures were the occurrence of serious complications. Admission to an intensive care unit (ICU) and 30-day mortality were secondary outcomes. The predictive performance of each score was analyzed. Five hundred seventy-one patients presented with febrile neutropenia. With MASCC risk index, 508 (89.1%) were classified as low-risk febrile neutropenia, compared to 60 (10.5%) with CISNE classification. Overall, the MASCC score had a greater discriminatory power in the detection of low-risk patients than the CISNE score (AUC 0.772, 95% CI 0.726-0.819 vs. 0.681, 95% CI 0.626-0.737, p = 0.0024). Both MASCC and CISNE scores have reasonable discriminatory value in predicting patients with low-risk febrile neutropenia. Risk scores should be used in conjunction with clinical judgment for the identification of patients suitable for outpatient management of neutropenic fever. Developing more accurate scores, validated in prospective settings, will be useful in facilitating more patients being managed in an outpatient setting.

Discrete choice experiment produced estimates of acceptable risks of therapeutic options in cancer patients with febrile neutropenia

ObjectiveTo use a discrete choice experiment (DCE) to describe patient/proxy tolerance for the number of clinic visits, and chances of readmission, intensive care unit admission, and mortality to accept oral outpatient management of low-risk febrile neutropenia. Study Design and SettingAdults and children aged 12–18 years with cancer and parents of pediatric cancer patients were asked to choose between outpatient oral and inpatient intravenous management of low-risk febrile neutropenia. Using a DCE, we varied the attribute levels with the outpatient option and kept them constant for the inpatient option. ResultsSeventy-eight adults, 153 parents, and 43 children provided responses. All four attributes significantly affected choices. The mean tolerance (95% confidence interval) for the number of clinic visits per week was 3.6 (2.2–4.8), 2.1 (1.1–3.2), and 4.3 (2.5–6.0) to accept outpatient management among adults, parents, and children, respectively. With thrice weekly clinic visits and 7.5% chance of readmission, probabilities of accepting the outpatient strategy were 50% (44–54%) for adults, 43% (39–48%) for parents, and 53% (46–59%) for children. ConclusionUsing a DCE, we determined that a 7.5% chance of readmission and clinic visits more frequently than thrice weekly are unlikely to be acceptable.

Outpatient and oral antibiotic management of low-risk febrile neutropenia are effective in children—a systematic review of prospective trials

There is no consensus on whether therapeutic intensity can be reduced safely in children with low-risk febrile neutropenia (FN). Our primary objective was to determine whether there is a difference in efficacy between outpatient and inpatient management of children with low-risk FN. Our secondary objective was to compare oral and parenteral antibiotic therapy in this population. We performed electronic searches of Ovid Medline, EMBASE, and the Cochrane Central Register of Controlled Trials, and limited studies to prospective pediatric trials in low-risk FN. Percentages were used as the effect measure. From 7,281 reviewed articles, 16 were included in the meta-analysis. Treatment failure, including antibiotic modification, was less likely to occur in the outpatient setting compared with the inpatient setting (15 % versus 28 %, P = 0.04) but was not significantly different between oral and parenteral antibiotic regimens (20 % versus 22 %, P = 0.68). Of the 953 episodes treated in the outpatient setting and 676 episodes treated with oral antibiotics, none were associated with infection-related mortality. Based on the combination of results from all prospective studies to date, outpatient and oral antibiotic management of low-risk FN are effective in children and should be incorporated into clinical care where feasible.

Advances in management of low-risk febrile neutropenia

To describe and discuss the most recent advances in the management of low-risk febrile neutropenia in children with cancer. Several risk stratification tools for children with febrile neutropenia have been developed, although none of these tools have been directly compared and few have been validated in independent populations. However, there is good evidence that, for pediatric patients with febrile neutropenia at low risk for severe infection, outpatient management is a well tolerated and efficacious alternative to inpatient care. Moreover, major progress has been made in obtaining and understanding perceived quality of life and preferences for outpatient management in pediatric cancer patients. Many parents prefer inpatient management although child quality of life is, in general, anticipated to be higher with outpatient intravenous therapy. Finally, outpatient strategies are more cost-effective as compared with traditional management in hospital. Outpatient management is a well tolerated and cost-effective strategy for low-risk febrile neutropenia in children with cancer, although parental preferences are highly variable for outpatient versus inpatient management. Future research should examine the effectiveness of outpatient strategies through conduct of large cohort studies. Other future work could focus on development of decision aids and other tools to facilitate ambulatory approaches.

Economic Comparison of Home-Care-Based versus Hospital-Based Treatment of Chemotherapy-Induced Febrile Neutropenia in Children

Objective The purpose of this study was to compare health-care resource utilization and outcomes among children treated for low-risk febrile neutropenia (FN) in a hospital-based setting with those treated in a home-care-based setting. Methods The perspective of this retrospective, cohort study was the health payer. We collected health-care utilization and treatment outcome data from medical records of 63 children (26 boys and 37 girls) with low-risk, chemotherapy-induced FN who were treated at the University of Arizona (27 children, the hospital-based group) and University of New Mexico (36 children, the home-care-based group). We identified 144 FN episodes (72 episodes in each group). Health-care utilization included physician visits, home-care visits, laboratory visits, outpatient visits, hospital days, intensive care unit days, medical tests and studies, and medications used to manage FN (e.g., filgrastim, antimicrobials, and ancilliary drugs and supplies). We applied uniform charges, based on those used at the University of New Mexico in 1998. We collected outcomes of the FN treatment (success vs. failure and time to resolution, defined as number of days of antibiotic therapy). Rates of positive blood cultures during treatment were also compared. Data were analyzed using nonparametric Mann–Whitney U tests for continuous data and chi-square analysis for categorical data. Sensitivity analyses were conducted by varying the amount of total resource utilization, as well as utilization of specific health-care resources. Results There was no difference in outcome; all episodes of treatment in both groups resulted in successful recovery from FN. Time to resolution of FN was 8.3 ± 2.7 days for home-care FN episodes versus 7.3 ± 3.6 days for hospital FN episodes ( P =.064). Median charge per FN episode was significantly ( P< .001) greater when managed in the hospital compared to home care ($9392 vs. $5893). There was greater use of laboratory and radiographic studies in the hospital-based patients ( P < .01). However, children in the home-care-based group were more often treated with granulocyte colony-stimulating factor (filgrastim, median charge $1085 vs. $451, P < .001), and median antibiotic charges were higher ($2523 vs. $1526, P < .001). Positive blood cultures were more common among the hospital-based FN treatments (30.6 vs. 11.1%, P=.012). Conclusions We found that management of low-risk FN in a home-care-based setting was associated with significantly lower median total charges with no differences in outcome.