Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients

Background We treated low-risk febrile neutropenic cancer patients utilizing two standard outpatient antibiotic pathways: oral ampicillin/clavulanate (500 mg) and ciprofloxacin (500 mg) or intravenous ceftazidime (2 g) and clindamycin (600 mg) every 8 h. The objectives were to determine the success of outpatient treatment of low-risk febrile neutropenia, to identify factors predicting outpatient failure, and to determine mortality related to the febrile episode.Methods Eligibility criteria included solid tumor diagnosis, stable vital signs, temperature 38.0°C, absolute neutrophil count (ANC) of <1000/ml, patient compliance, no significant organ dysfunction, ability to tolerate oral medication and fluids for oral pathway, residence within 30 miles of the institution, 24-h caregiver, and telephone and transportation access.Results There were 257 febrile episodes in 191 patients meeting the criteria. Patients were treated during March 1998 through February 2000. Median age was 48 (range, 17–77) years, and 60% (n=153) had an entry ANC of <100/ml; 205 (80%) febrile episodes successfully responded to outpatient treatment, and 52 (20%) were hospitalized. Logistic regression analysis showed the following were related to hospitalization: mucositis >grade 2 (p <0.002); Zubrod performance status 2 (p=0.029); ANC <100/ml (p=0.039), and age 70 years (p=0.048).Conclusions Outpatient treatment of low-risk febrile neutropenic cancer patients utilizing standard treatment pathways is associated with minimal morbidity and mortality and should be considered an acceptable standard of care with appropriate infrastructure available to provide strict and careful follow-up while on treatment. Certain factors are associated with higher risk of hospitalization and should be further examined in eligible patients with low-risk febrile neutropenia.Presented at the 2002 American Society of Clinical Oncology, Orlando, Florida, USA.     

Domiciliary treatment of febrile episodes in cancer patients: a prospective randomized trial comparing oral versus parenteral empirical antibiotic treatment

Hospitalization and empirical broad-spectrum, intravenous antibiotics are the standard treatment for febrile cancer patients. Recent evidence supports the suggestion that febrile episodes in a low-risk population can be managed successfully in an outpatient setting, but the optimal drug regimen is unknown. In a prospective randomized clinical trial we compared ciprofloxacin 750 mg p.o. twice a day with ceftriaxone 2 g i.v. as a single daily dose for the empiric domiciliary treatment of febrile episodes in low-risk neutropenic and nonneutropenic cancer patients. A total of 173 patients, accounting for 183 febrile episodes, were enrolled in the study. Overall, successful outcomes were recorded for 76 of 93 (82%) febrile episodes in patients who were randomized to the oral regimen and for 68 of 90 (75%) febrile episodes in patients randomized to the i.v. regimen: this difference was not statistically significant. The success rate was similar in all subgroups of patients: neutropenic and nonneutropenic, with documented infection and with fever of unknown origin. There were 3 deaths in the group of patients treated with the parenteral regimen, and two of these were related to treatment failure. Both treatments were well tolerated, and the cost of the oral regimen was lower. This prospective study suggests that domiciliary antibiotic empiric monotherapy is feasible in febrile nonneutropenic or low-risk neutropenic outpatients in whom a bacterial infection is suspected, and that either an oral or a parenteral regimen can be used. A number of factors may influence the choice between an orally and an i.v.-administered antibiotic, but owing to the easier administration and lower cost, the oral regimen seems to be preferable. Published online: 5 March 1999     

Prophylactic antibiotics eliminate bacteremia and allow safe outpatient management following high-dose chemotherapy and autologous stem cell rescue

This study examines the effectiveness of prophylactic ciprofloxacin and rifampin following high-dose chemotherapy and autologous stem cell rescue (HDC/ASCR). Specific endpoints included the incidence of fever, clinically documented infection, bacteremia, and readmission rates from an outpatient bone marrow transplant setting following infection or fever. A group of 97 patients receiving 134 cycles of HDC/ASCR were studied. Patients were given ciprofloxacin 750 mg p.o. twice daily and rifampin 300 mg p.o. twice daily beginning on the day of stem cell reinfusion (24-48 h after completion of high-dose chemotherapy). Most patients were either discharged to an outpatient setting following completion of their chemotherapy or received all of their chemotherapy in an outpatient setting. Febrile neutropenia was treated with empirical antibiotics in an outpatient setting unless it was complicated by hypotension, renal failure, severe mucositis or other problems. The median duration of neutropenia (absolute neutrophil count below 500/mm³) was 7 days. Neutropenic fever occurred in 62% of patients but clinically documented bacterial infection occurred in only 2 (1.5%) patients during their neutropenic period. No bacteremia was noted. Readmission to the hospital following fever or infection occurred in 26% of patients maintained in the outpatient setting. There were no deaths from a bacterial infection in this study although 1 patient (0.7%) died from aspergillosis. Prophylactic ciprofloxacin and rifampin is a well-tolerated and highly effective combination that effectively decreases the risk of both gram-positive and gram-negative bacterial infection following HDC/ASCR. It facilitates outpatient management of myelosuppressed patients receiving autologous stem cell rescue.Presented in part as an invited lecture at the 7th International Symposium: Supportive Care in Cancer, Luxembourg, 20–23 September 1995     

Outpatient high-dose melphalan in multiple myeloma patients

BACKGROUND: The brief period of neutropenia and limited nonmarrow toxicity after high-dose melphalan (HDM) provide a rationale for outpatient treatment. STUDY DESIGN AND METHODS: Our experience with HDM (140-200 mg/m(2)) in 90 consecutive transplant episodes was retrospectively reviewed. Most patients were treated in an outpatient setting. Patients without a primary care provider (PCP) were electively admitted before the anticipated onset of neutropenia. Ceftriaxone was added to ciprofloxacin at the onset of neutropenia. All febrile patients were admitted. RESULTS: The median time from peripheral blood progenitor cell infusion to onset of neutropenia was 5 days (range, 4-6 days), and the mean duration of neutropenia was 5 days (range, 4-7 days). Thirty-eight transplants (42%) were performed entirely in the outpatient setting. The mean duration of hospitalization was 2.2 days in patients not electively admitted. The use of ceftriaxone was associated with a decreased risk for fever (39% vs. 79%) and reduced duration of hospitalization (1.6 days vs. 4.5 days) for nonelectively admitted patients. There was no treatment-related mortality. CONCLUSION: Ambulatory therapy with HDM is safe and can be achieved in a general outpatient setting. The predictable time to neutropenia allows even poor candidates for outpatient therapy to be admitted electively on Day +4. The apparent beneficial effect of ceftriaxone needs to be confirmed in randomized trials.     

Prospective study of empiric monotherapy with ceftazidime for low-risk grade IV febrile neutropenia after cytotoxic chemotherapy in cancer patients

PURPOSE: It was the aim of this study to evaluate the results of a prospective study in a single medical center using ceftazidime monotherapy in cancer patients with chemotherapy-induced grade IV febrile neutropenia and a low risk for gram-negative bacteremia. SUBJECTS AND METHODS: Thirty-eight patients were admitted with low-risk grade IV febrile neutropenia after chemotherapy for solid tumors. The median patient age was 57 years (range 18-74). Sixteen patients (42%) developed febrile neutropenia after the first cycle of current chemotherapy line, 9 patients (24%) received 2-3 cycles and 13 patients (34%) received more than 3 chemotherapy cycles before manifesting febrile neutropenia. Five patients were treated with prophylactic granulocyte colony-stimulating factor commenced 24 h after completion of the chemotherapy cycle. Empiric monotherapy with intravenous ceftazidime was started on admission and administered 2 g every 8 h. RESULTS: The mean polymorphic nuclear cell count on admission was 231 cells/mm(3). Ceftazidime therapy was well tolerated. Twenty-five (66%) patients responded with clinical improvement and complete resolution of fever within 48 h after initiation of ceftazidime therapy. Thirty-two (84%) patients were afebrile after 72 h of therapy. Thirty-three patients (87%) remained on unmodified ceftazidime therapy throughout their hospitalization. Five patients (13%) subsequently required modification of the treatment regimen for various reasons. Mean duration of fever and neutropenia were 2 (1-10) days and 4 (1-11) days, respectively. None of the patients discontinued therapy because of adverse effects. No positive blood cultures were obtained. No events of septic shock were observed. Mean duration of hospitalization was 6 days (range 3-12). CONCLUSION: In our series, monotherapy with intravenous ceftazidime appears safe and effective in cancer patients with low-risk grade IV febrile neutropenia after cytotoxic chemotherapy and may appreciably reduce antibiotics costs.     

Emergency department management of chemotherapy related febrile neutropenia: An opportunity to improve care

BackgroundFebrile neutropenia (FN) is an important oncological emergency seen in the emergency department (ED), and the American Society of Clinical Oncology recommends risk stratification of patients with febrile neutropenia using the Multinational Association for Supportive Care in Cancer (MASCC) Index, with ED discharge on oral antibiotics recommended for low-risk patients.ObjectivesTo determine the prevalence of FN neutropenia and medical system wide ED treatment guideline adherence.MethodsWe performed a retrospective chart review of all patients with an ICD-10 confirmed diagnosis of FN from January 2016-2019at 13 affiliated EDs within one medical system. Only cancer/chemotherapy related FN were included. Following the MASCC guidelines, we used post-hoc calculations to classify patients as low/high-risk, and compared key clinical variables (mortality, blood culture positivity, interventions).Results203 patients were found to have FN. 97.9% (184/203) received broad spectrum antibiotics, including 92% of the low-risk group (60/65). All patients were admitted, and no observed in-hospital mortality was noted in the low-risk group, meanwhile 5.1% (7/138) of the high-risk group died. 14/203 patients had positive blood cultures, none in the low-risk group.ConclusionThe prevalence of FN is low among 13 EDs that had almost 1.7 million ED visits over a 3-year period. Guideline compliance for low-risk FN was poor. All patients were admitted, and nearly all patients received IV fluids and IV antibiotics. Improving FN management to align with national guidelines represents an opportunity to improved ED care of patients with cancer by reducing unnecessary hospitalizations.     

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

Background  

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.     

Clinical practice patterns of managing low-risk adult febrile neutropenia during cancer chemotherapy in the USA

PURPOSE: The purpose of the study was to determine oncologists' current practice patterns for antibiotic management of low-risk fever and neutropenia (FN) after chemotherapy. MATERIALS AND METHODS: A self-administered survey was developed to query management practices for low-risk FN patients and sent to 3,600 randomly selected American Society of Clinical Oncology physician members; hypothetical case scenarios were included to assess factors influencing decisions about outpatient treatment. RESULTS: Of 3,560 actively practicing oncologists, 1,207 replied (34%). Outpatient antibiotics are used by 82% for selected low-risk FN patients (27% used in them >65% of their patients). Oral levofloxacin (50%), ciprofloxacin (36%), and ciprofloxacin plus amoxicillin/clavulanate (35%) are common outpatient regimens. Fluoroquinolone prophylaxis is used by 45% of oncologists, in a subset of afebrile patients at low risk for FN; growth factors are used adjunctively by 48% for treating low-risk FN. Factors associated with choosing outpatient treatment were: frequency of use in oncologists' own practices, absence of hematologic malignancy, lower patient age, no infiltrate on X-ray, no prior serious infection, shorter expected FN duration, lower creatinine levels, and shorter distance of patient's residence from the hospital. CONCLUSIONS: US oncologists, who responded are willing to prescribe outpatient oral antibiotic treatment for low-risk FN, although practices vary considerably and are based on favorable clinical factors. However, practices are often employed that are not recommended for low-risk patients by current guidelines, including fluoroquinolone prophylaxis, adjunctive and/or prophylactic growth factors, and use of levofloxacin for empiric therapy. Educational efforts are needed to better guide cost-effective and supportive care.     

Cefepime monotherapy for febrile neutropenia in patients with lung cancer

We assessed the efficacy and safety of cefepime monotherapy (1 g intravenously every 8 h) for febrile neutropenia in patients with lung cancer in a multi-institutional phase II study. Patients treated with chemotherapy with or without radiotherapy for lung cancer were eligible for this study. Other eligibility criteria included fever (temperature of ≥38.0 °C) and an absolute neutrophil count of <500/mm³ or <1000/mm³ with an expected decline to <500/mm³ within the next 48 h. Risk assessment was performed using the Multinational Association of Supportive Care in Cancer risk-index score. Cefepime 1 g was given intravenously every 8 h. The primary endpoint was the response rate at the end of cefepime therapy. Co-administration of granulocyte-colony-stimulating factor was permitted. Of 54 patients enrolled, 39 were classified in the low-risk group and 15 in the high-risk group. Overall response rate was 78% (95% CI: 64.4–88.0%). The response rates were 85% (95% CI: 69.5–94.1%) in the low-risk group and 60% (95% CI: 32.3–83.7%) in the high-risk group, respectively. One patient died from septic shock due to Enterobacter cloacae bacteremia. There was no significant adverse event. Cefepime 1 g intravenously every 8 h appears to be effective for febrile neutropenia in patients with lung cancer, especially in those with low-risk febrile neutropenia, and is well tolerated.Clinical trial registrationUMIN Clinical Trials Registry, UMIN000006157.     

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.     

Phase 1/2 clinical study of irinotecan and oral S-1 (IRIS) in patients with advanced gastric cancer

Background

Irinotecan and S-1, an oral fluoropyrimidine composed of tegafur, gimeracil, and oteracil potassium, have demonstrated antitumor activity against advanced gastric cancer. We performed a phase 1/2 study to determine the recommended dose, antitumor activity, and safety of a combination of S-1 and irinotecan in patients with advanced gastric cancer.

Methods

Patients with previously untreated advanced gastric cancer were enrolled. Patients received irinotecan intravenously on days 1 and 15 plus oral S-1 twice daily on days 1–14 of a 28-day cycle. In the phase 1 part, the dose of irinotecan was escalated from 100 mg/m² to 125 mg/m² and then to 150 mg/m².

Results

A total of 24 patients were enrolled. Overall, the median number of treatment cycles per patient was 5.9, and 92% of the patients completed at least two cycles. The overall response rate was 54.2% (13 of 24). The response rates in differentiated and undifferentiated cancer were 56.3% (nine of 16) and 50.0% (four of eight), respectively. Median survival time was 581 days. The maximum tolerated dose of irinotecan was not reached at the highest level. However, grade 4 neutropenia occurred at 125 mg/m². We concluded that the recommended dose of irinotecan for the present regimen was 125 mg/m².

Conclusion

Treatment with S-1+irinotecan is considered effective in patients with advanced gastric cancer who have not previously received chemotherapy. A combination of irinotecan and S-1 was well tolerated in patients with advanced gastric cancer and could be given on an outpatient basis.     

Monotherapy with intravenous followed by oral high-dose ciprofloxacin versus combination therapy with ceftazidime plus amikacin as initial empiric therapy for granulocytopenic patients with fever

The aim of the present study was to obtain clinical experience with the use of high-dose ciprofloxacin as monotherapy for the treatment of febrile neutropenia episodes (granulocyte count, <500/mm(3)) compared to a standard regimen and to clarify whether ciprofloxacin administration may be switched to the oral route. In a prospective randomized study ciprofloxacin was given at 400 mg three times a day (t.i.d.) for at least 72 h followed by oral administration at 750 mg twice a day (b.i.d). That regimen was compared with ceftazidime given intravenously at 2 g t.i.d. plus amikacin given intravenously at 500 mg b.i.d. The frequency of successful clinical response without modification at the end of therapy was almost identical for ciprofloxacin (50% [62 of 124 patients]) compared with that for ceftazidime plus amikacin (50.8% [62 of 122 patients]) in an intent-to-treat analysis; the frequencies were 48.3% (57 of 118 patients) versus 49.6% (56 of 113 patients), respectively, in a per-protocol analysis (P values for one-sided equivalence, 0.0485 and 0.0516, respectively; delta = 10%), with no significant differences among patients with bacteremia and other microbiologically or clinically documented infections and fever of unknown origin. For 82 (66.1%) patients, it was possible to switch from parenteral ciprofloxacin to the oral ciprofloxacin, and the response was successful for 61 (74.4%) patients. The efficacies of the regimens against streptococcal bacteremias were 16.6% (one of six patients) for the ciprofloxacin group and 33.3% (one of three patients) for the combination group (it was not statistically significant), with one breakthrough streptococcal bacteremia observed among the ciprofloxacin-treated patients. Adverse events were mostly self-limited and were observed in 27 (20.6%) ciprofloxacin-treated patients and 26 (19.7%) patients who were receiving the combination. This study demonstrates that high-dose ciprofloxacin given intravenously for at least 3 days and then by the oral route is therapeutically equivalent to the routine regimen of intraveneous ceftazidime plus amikacin even in febrile patients with severe neutropenia (polymorphonuclear leukocyte count, <100 mm(3)). However, it is very important that before an empirical therapy is chosen each hospital determine bacteriologic predominance and perform resistance surveillance.     

Risk-adapted strategy for the management of febrile neutropenia in cancer patients

Background Among patients who develop fever and neutropenia after having received cancer chemotherapy, we have to distinguish at least three categories of risk levels for complications and death: patients at low risk and eligible for oral treatment and possibly outpatient management, patients at low risk who require intravenous therapy, and patients at higher risk. Results and discussion The Multinational Association for Supportive Care in Cancer scoring system identifies patients at low risk (<5%) of severe complications with very low mortality (<1%) during an episode of febrile neutropenia; this group represents roughly 70% of an unselected population of patients with febrile neutropenia. A significant percentage (≈50%) of these patients are eligible for treatment with orally administered antibiotics and can be discharged early and safely from the hospital after a short (24–48 h) observation period.     

Does ciprofloxacin prophylaxis during chemotherapy induce intestinal microflora resistance to ceftazidime in children with cancer?

To determine the susceptibility and minimal inhibitory concentrations (MIC) of ceftazidime, the commonly used empirical antibiotic in patients with febrile neutropenia, in Escherichia coli and Klebsiella pneumoniae isolated from the intestinal microflora of pediatric patients with cancer, who received ciprofloxacin prophylaxis during chemotherapy, children younger than 18 years with acute lymphoblastic leukemia or lymphoma scheduled to undergo chemotherapy were randomized to receive oral ciprofloxacin 20 mg/kg/day or placebo from the beginning of their chemotherapy. Rectal swab cultures were taken before (R0) and at 1 (R1), 2 (R2), and 3 (R3) weeks during the intervention. The antimicrobial susceptibilities and MICs of ceftazidime and ciprofloxacin were determined via the E test. Of the total 87 patients enrolled, 44 received ciprofloxacin and 43 placebo. A total of 350 isolates were obtained, 62, 49, 46 and 22 from the ciprofloxacin group and 68, 54, 38 and 11 from the placebo group at R0, R1, R2 and R3, respectively. The percentages of ceftazidime susceptibility did not show significantly greater decreases from R0 to R1-R3 in the ciprofloxacin group compared to the placebo group. The MIC₅₀s of ceftazidime showed significantly greater increases after ciprofloxacin prophylaxis during R1-R3 compared to R0 in the intervention group compared to the placebo group (R0, 0.12 vs. 0.12; R1, 0.19 vs. 0.12; R2, 0.19 vs. 0.12 and R3, 0.38 vs. 0.09 μg/mL, respectively). Due to the increasing MIC₅₀ of ceftazidime over time after ciprofloxacin prophylaxis, the use of ceftazidime in patients who have previously had ciprofloxacin prophylaxis needs to be closely monitored.     

Febrile neutropenia: a prospective study to validate the Multinational Association of Supportive Care of Cancer (MASCC) risk-index score

Objective The objective of this study was to prospectively validate the Multinational Association of Supportive Care of Cancer (MASCC) risk-index score in an attempt to accurately predict on presentation with febrile neutropenia those cancer patients who are at low- or high-risk for development of serious medical complications during the episode.Patients and methods Patients who presented with febrile neutropenia during November 2000 and July 2002 were prospectively enrolled in the protocol. All patients were hospitalized until recovery or outcome of the event and were treated with broad-spectrum, empiric, intravenous antibiotic therapy. The MASCC risk-index score (based on seven independent factors present at onset of febrile neutropenia) was calculated in 64 patients with 80 febrile neutropenic episodes. Patients with a score of 21 were regarded as low risk; patients with a score of <21 were regarded as high risk.Results Of the 80 febrile neutropenic episodes, 58 were classified as low-risk and 22 as high-risk patients. Fifty-seven (98.3%) of the 58 low-risk patients recovered without complications, and three (13.6%) of the 22 high-risk patients did not develop medical complications. One low-risk patient developed a fungal infection but recovered completely in comparison to 11 high-risk patients (50%) who developed serious medical complications (p<0.001). None of the low-risk patients died. However, eight (36.4%) of the 22 high-risk patients died during the febrile neutropenic episode (p<0.001), six as a consequence of sepsis and two due to rapidly uncontrolled cancer.Conclusion We correctly predicted 98.3% of low-risk patients and 86.3% of high-risk patients. This study had a positive predictive value of 98.3% and a negative predictive value of 86.4% with both a sensitivity and specificity of 95%. The MASCC risk-index score correctly identifies low- and high-risk patients at presentation with febrile neutropenia.     

Expanding the Options for Risk-based Therapy in Febrile Neutropenia

Fever in neutropenic cancer patients is often due to the development of an infection. The standard management of febrile neutropenic patients involves the administration of empiric, hospital-based, parenteral antibiotic therapy. Although this treatment strategy has evolved from experience in high-risk patients with hematological malignancies, in whom bacterial infection can result in substantial morbidity and mortality, it has been adopted for all patients with febrile neutropenia, largely because of the inability of clinicians to reliably distinguish between patients who are at high risk for developing such morbidity/mortality and those who are not. The development of risk-assessment models has facilitated the recognition of high-, moderate-, and low-risk subgroups among febrile neutropenic patients and allows the administration of outpatient antibiotic therapy to the moderate- and low-risk groups, with the same degree of efficacy and safety as hospital-based therapy. Monotherapy with the carbapenems (imipenem/cilastatin and meropenem), with their broad spectrum of activity and established efficacy in high-risk patients, represents realistic options for risk-based treatment of febrile neutropenic patients within and outside the hospital setting.     

Outpatient antibiotic treatment in low-risk febrile neutropenic cancer patients

Traditionally febrile neutropenic patients have been treated with parenteral antibiotics in an inpatient setting; however, recent work by several investigators has demonstrated successful treatment with both parenteral and oral antibiotics in an ambulatory environment. This has been accomplished by identification of low-risk neutropenic patients, advances in broad-spectrum antibiotics with long half-lives and stabilities, the introduction of the oral quinolones, home health-care initiatives, improvements in vascular access devices, and development of technically enhanced antibiotic delivery systems. Outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients should now be considered an acceptable alternative to hospital-based treatment. This review focuses on the development and rationale of risk stratification and examines the results of various outpatient antibiotic trials recently completed.     

Management of febrile neutropenia in solid tumours and lymphomas using the Multinational Association for Supportive Care in Cancer (MASCC) risk index: feasibility and safety in routine clinical practice

Goals of work Febrile neutropenia (FN) represents a spectrum of severity in which low-risk patients can be defined using the Multinational Association for Supportive Care in Cancer (MASCC) risk index. However, despite publication in 2000, there remains limited published literature to date to support the use of MASCC risk assessment in routine clinical practice and eligibility for early hospital discharge. In this study, we present our experience with the routine use of the MASCC risk index to determine the management of FN in our institution. Patients and methods Patients treated for solid tumours or lymphomas with low-risk FN (MASCC score ≥21) were eligible for oral antibiotics (ciprofloxacin plus either co-amoxiclav or doxycycline) and for early hospital discharge irrespective of first or subsequent episode. The primary outcome was rate of resolution of FN without serious medical complications (SMC). Secondary outcomes were the “success” of antibiotic therapy without treatment modifications, duration of hospitalisation and rate of readmissions. Results A total of 100 FN episodes occurring in 83 patients were treated over a 6-month period. Ninety of these episodes were low-risk (90%), of which 75 received oral antibiotics (83.3%) and 3 (3.3%) experienced SMC, and the success rate was 94.5% [95% confidence interval (CI) 89.6–99.3%] in low-risk episodes. The median duration of hospitalisation was 2.5 days (25th centile: 1.0 day; 75th centile: 5.0 days) in low-risk compared to 6.5 days (25th centile: 5.3 days; 75th centile: 9.3 days) in high-risk episodes (p = 0.003); 2 days for low-risk episodes treated with oral antibiotics compared to 4 days for low-risk receiving intravenous antibiotics (p = 0.015). Positive predictive value for the MASCC index was 96.7% (95% CI 95.0–98.6%). Conclusion The MASCC risk index is both feasible and safe when used in standard clinical practice to guide the management of FN in patients with solid tumours and lymphomas. Patients predicted to have low risk can be managed safely with oral antibiotics and early hospital discharge.     

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

BackgroundEmergency 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.ObjectivesWe sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion.MethodsPatients 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.ResultsOne 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.ConclusionOutpatient 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.     

Efficacy of a 14-day course of oral ciprofloxacin therapy for acute uncomplicated pyelonephritis

This study aimed to evaluate the efficacy and safety of oral antibacterial treatment with fluoroquinilone for acute uncomplicated pyelonephritis Thirteen female patients with acute uncomplicated pyelonephritis were treated with oral fluoroquinilone (ciprofloxacin; CPFX). They received 200 mg of the drug three times a day while febrile (3–5 days). Once they become afebrile, the same dose of the drug, given twice a day, was given for another 9–11 days. The mean duration of the course of CPFX was 14 days. Symptoms were evaluated, and laboratory examinations, including urine culture and measurement of the minimal inhibitory concentration (MIC) of CPFX were conducted before treatment, and 3, 7, 14, 21, and/or 28 days after the initiation of the treatment. Of the 13 patients, only 5 needed to be hospitalized, and the period of hospitalization was only a few days. On the 14th day after the commencement of treatment, bacteriologic and clinical cure rates were 100%. Escherichia coli was the most common uropathogen, being isolated from the urine of 8 patients. No clinical relapse of the disease was found during a follow-up period of up to 4 weeks. The patients tolerated the drug well without developing any serious adverse effects. Oral antimicrobial chemotherapy with fluoroquinolone, given on an outpatient or short-term hospitalization basis, achieved satisfactory bacteriological and clinical outcomes in the treatment of acute uncomplicated pyelonephritis. This treatment regimen is indicated for patients with this disease who are not in a serious condition with complications such as shock. Received: January 29, 2001 / Accepted: April 7, 2001