Feasibility of outpatient management of fever in cancer patients with low-risk neutropenia: results of a prospective randomized trial

"Low-risk" prediction rule for pediatric oncology patients presenting with fever and neutropenia

PURPOSE

To prospectively derive and validate a clinical prediction rule to allow a more tailored approach to the management of pediatric oncology outpatients presenting with fever and neutropenia.

PATIENTS AND METHODS

The clinical prediction rule was derived over a 1-year period and then validated over the following 8 months in a new set of fever and neutropenia episodes. Patients were excluded if they presented with comorbidity or an abnormal chest x-ray (CXR).

RESULTS

Significant bacterial infection (SBI; defined as any blood or urine culture positive for bacteria, interstitial or lobar consolidation on CXR, or unexpected death from infection) was documented in 43 of the 227 episodes. Multivariate analysis found four significant factors: bone marrow disease, general appearance unwell on initial examination, monocyte count less than 0.1 x 10(9)/L, and peak oral or oral equivalent temperature greater than 39 degrees C. Only the monocyte count contributed to determining a low-risk group, excluding SBI with 84% sensitivity (95% confidence interval [CI], 61% to 100%), 42% specificity (95% CI, 38% to 46%), and a negative predictive value of 92% (95% CI, 76% to 100%). If the monocyte count was >/= 0.1 x 10(9)/L at the time of presentation (low risk), the incidences of SBI and bacteremia were 8% and 5%, respectively, versus 25% and 17% in the high-risk group. When validated in a new population of 136 episodes of fever and neutropenia, the incidences of SBI and bacteremia in the low-risk group were 12% and 5%, respectively, and 25% and 19% in the high-risk group.

CONCLUSION

Pediatric oncology outpatients with fever and neutropenia who present with an initial monocyte count of >/= 0.1 x 10(9)/L and do not have comorbidity or an abnormal CXR at the time of presentation are at lower risk for SBI and can be considered for less aggressive initial therapy.

Intensified primary cancer care: a randomized study of home care nurse contacts

Newly diagnosed cancer patients (n=527) were randomised to intensified primary care or a control group. Intensified primary care comprised routines to improve general practitioners' and home care nurses' possibilities to support and monitor patients, i.e. increased information from specialist care, education and supervision in cancer care. The aims of this paper are to evaluate the effects of intensified primary care on cancer patients' home care nurse contacts, and to study if patients' use of home care services 6 months after diagnosis can be predicted. The intervention resulted in a marked increase of follow-up contacts. About 90% of intensified primary care patients reported such contacts, compared to 26% of control patients. The results indicate that standard care does not routinely include follow-up contacts, not even for the oldest (80+ years) or those with advanced disease. Only 27% and 36% of these groups of control patients reported follow-ups. Logistic regression analysis identified intensified primary care as the strongest predictor for reporting a continuing contact 6 months after diagnosis. Intensified primary care patients were 14 times more likely than controls to report a such contact. The strongest predictor of a continuing contact in the intensified primary care group was high age. Patients with advanced disease were more likely than patients with non-advanced disease to report a continuing contact, and living in a rural district was positively associated with reporting a contact. A majority of the patients (70%) assessed the time for the first contact as the 'right time' and estimated that the nurse gave expected support to a very large or large extent (67%). The results suggest that routines like those implemented through intensified primary care may be an effective strategy to increase the accessibility and continuity of care, especially for elderly people and for patients with a need for long-term contacts.

Empiric antimicrobial therapy of febrile neutropenic patients undergoing haematopoietic stem cell transplantation

This study was conducted to assess the efficacy and toxicity of intravenous (i.v.) ceftazidime and ciprofloxacin in neutropenic febrile patients undergoing high dose myeloablative therapy and hematopoietic stem cell transplantation (HSCT). All patients undergoing HSCT for leukaemia, lymphoma, multiple myeloma and solid tumours received open-label ceftazidime 2 g i.v. every 8 h and ciprofloxacin 400 mg i.v. every 12 h if they developed fever while they were neutropenic. Success with or without modification of this regimen was defined as survival through the neutropenic period; failure was defined as death secondary to infection. Of 106 patients treated with this regimen, the success rate was 99%. Sixty-one of the patients (57.5%) defervesced within 48-72 h and remained afebrile without regimen modification. In 41.5% of the cases (44/106), the regimen was modified because of persistent fever. One patient died secondary to sepsis. The combination of ceftazidime and ciprofloxacin as initial empiric antibacterial therapy in febrile neutropenic patients undergoing myeloablative therapy and HSCT is highly effective and is associated with minimal toxicity.

Oral versus intravenous empirical antimicrobial therapy for fever in patients with granulocytopenia who are receiving cancer chemotherapy. International Antimicrobial Therapy Cooperative Group of the European Organization for Research and Treatment of Cancer

BACKGROUND

Intravenously administered antimicrobial agents have been the standard choice for the empirical management of fever in patients with cancer and granulocytopenia. If orally administered empirical therapy is as effective as intravenous therapy, it would offer advantages such as improved quality of life and lower cost.

METHODS

In a prospective, open-label, multicenter trial, we randomly assigned febrile patients with cancer who had granulocytopenia that was expected to resolve within 10 days to receive empirical therapy with either oral ciprofloxacin (750 mg twice daily) plus amoxicillin-clavulanate (625 mg three times daily) or standard daily doses of intravenous ceftriaxone plus amikacin. All patients were hospitalized until their fever resolved. The primary objective of the study was to determine whether there was equivalence between the regimens, defined as an absolute difference in the rates of success of 10 percent or less.

RESULTS

Equivalence was demonstrated at the second interim analysis, and the trial was terminated after the enrollment of 353 patients. In the analysis of the 312 patients who were treated according to the protocol and who could be evaluated, treatment was successful in 86 percent of the patients in the oral-therapy group (95 percent confidence interval, 80 to 91 percent) and 84 percent of those in the intravenous-therapy group (95 percent confidence interval, 78 to 90 percent; P=0.02). The results were similar in the intention-to-treat analysis (80 percent and 77 percent, respectively; P=0.03), as were the duration of fever, the time to a change in the regimen, the reasons for such a change, the duration of therapy, and survival. The types of adverse events differed slightly between the groups but were similar in frequency.

CONCLUSIONS

In low-risk patients with cancer who have fever and granulocytopenia, oral therapy with ciprofloxacin plus amoxicillin-clavulanate is as effective as intravenous therapy.

A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy

BACKGROUND

Among patients with fever and neutropenia during chemotherapy for cancer who have a low risk of complications, oral administration of empirical broad-spectrum antibiotics may be an acceptable alternative to intravenous treatment.

METHODS

We conducted a randomized, double-blind, placebo-controlled study of patients (age, 5 to 74 years) who had fever and neutropenia during chemotherapy for cancer. Neutropenia was expected to be present for no more than 10 days in these patients, and they had to have no other underlying conditions. Patients were assigned to receive either oral ciprofloxacin plus amoxicillin-clavulanate or intravenous ceftazidime. They were hospitalized until fever and neutropenia resolved.

RESULTS

A total of 116 episodes were included in each group (84 patients in the oral-therapy group and 79 patients in the intravenous-therapy group). The mean neutrophil counts at admission were 81 per cubic millimeter and 84 per cubic millimeter, respectively; the mean duration of neutropenia was 3.4 and 3.8 days, respectively. Treatment was successful without the need for modifications in 71 percent of episodes in the oral-therapy group and 67 percent of episodes in the intravenous-therapy group (difference between groups, 3 percent; 95 percent confidence interval, -8 percent to 15 percent; P=0.48). Treatment was considered to have failed because of the need for modifications in the regimen in 13 percent and 32 percent of episodes, respectively (P<0.001) and because of the patient's inability to tolerate the regimen in 16 percent and 1 percent of episodes, respectively (P<0.001). There were no deaths. The incidence of intolerance of the oral antibiotics was 16 percent, as compared with 8 percent for placebo (P=0.07).

CONCLUSIONS

In hospitalized low-risk patients who have fever and neutropenia during cancer chemotherapy, empirical therapy with oral ciprofloxacin and amoxicillin-clavulanate is safe and effective.

Outpatient parenteral antibiotic therapy for fever and neutropenia

The treatment of fever and neutropenia following chemotherapy lends itself well to outpatient parenteral antimicrobial therapy (OPAT). Patients prefer to be at home rather than hospitalized again. There is a clear cost advantage of outpatient therapy. With a quality program and careful patient selection, OPAT can be provided effectively and safely. The chances of an infection due to resistant bacteria also appear to be reduced. There are an increasing number of studies that support the use of empiric antibiotic therapy for the first fever in neutropenic patients. The choice of antimicrobial, dose, as well as vascular access and infusion devices must be tailored to the individual patient needs and circumstances.

Ambulatory management of chemotherapy-induced fever and neutropenia in adult cancer patients

OBJECTIVE

To review the literature on the management of low-risk adults with chemotherapy-induced fever and neutropenia (CIFN). Included in the review are methods to identify these patients, management options, and economic impact associated with nontraditional treatment options.

DATA SOURCES

A MEDLINE and bibliographic search (January 1966-December 1997) for all English-language studies evaluating the identification and treatment of adult, low-risk CIFN patients was completed. Reference lists from identified articles also served as literature sources.

STUDY SELECTION AND DATA EXTRACTION

All human studies identified from the data sources were evaluated. Pertinent information, excluding pediatric studies, was selected and critically evaluated for discussion.

DATA SYNTHESIS

Alterations in prominent bacterial isolates in CIFN, newer antibiotic choices, enhanced focus on patient comfort, and cost-containment directives have promoted recent research identifying adult cancer patients with low-risk CIFN. Using this information to select low-risk CIFN patients, several investigators have completed trials using antibiotic therapy applicable to the ambulatory setting. Additionally, some investigators have included the use of an oral outpatient antibiotic regimen. Limited data indicate that this approach is a reasonable treatment option for selected patients.

CONCLUSIONS

A subset of adult patients with CIFN are at low risk for serious morbidity and mortality when treated with broad-spectrum antibiotics in the ambulatory setting. Managing these patients with this approach requires close patient selection, intense follow-up, data collection, and ongoing evaluation to determine efficacy and patient safety. Currently, ambulatory treatment with oral antibiotics for CIFN is not considered standard of care. Further studies of larger size designed to confirm low-risk patient characteristics and optimal antibiotic selection are required.

[Febrile neutropenia: practical aspects]

BACKGROUND

Infections are a major cause of mortality in neutropenic patients. They require long hospital stays and highly expensive therapeutic measures. In this review we discuss the practical and pharmaco-economic aspects of the management of febrile neutropenia.

PREVENTION AND THERAPY

Prevention of fever of unknown origin (FUO) demands hygienic and antimicrobiotic measures. First-line antibiotic therapy consists of an aminoglycoside combined with an ureidopenicillin or a 3rd-generation cephalosporin. Double beta-lactam antibiotic combinations are equally effective and less toxic, but more expensive. Monotherapy with carbapenems, ceftazidime, or cefepime appear to offer comparable efficacy. Lung infiltrates require immediate treatment with amphotericin B. If the initial therapeutic regime fails, a carbapenem plus a glycopeptide antibiotic and a parenteral antimycotic drug should be applied after 3 to 4 days. The prophylactic or interventional administration of hematopoietic growth factors is only indicated in special high-risk situations.

CONCLUSIONS

Using the described therapeutic procedure, the response rate exceeds 90%. Consistent, step-wise escalating administration of antibiotics is essential. More evaluation is needed to determine whether selected patients with febrile neutropenia can be treated on an outpatient basis.

Ceftriaxone in the outpatient treatment of cancer patients with fever and neutropenia

A study was performed in low-risk cancer patients with chemotherapy-induced febrile neutropenia to determine the safety and efficacy of ceftriaxone given in an outpatient setting. A total of 126 episodes of febrile neutropenia in 120 clinically stable outpatients were treated with intravenous ceftriaxone alone (n=100) or in combination with other antibiotics (n=26). The mean neutrophil count was 460/mm3; severe neutropenia (< 100/mm3) was observed in 18 episodes. The initial treatment with ceftriaxone (alone or in combination) was successful in 99 episodes (78%). Ninety-five episodes (76%) were successfully treated in an outpatient setting only; admission to hospital was necessary in 31 episodes (24%), but no infection-related death was observed. Ceftriaxone seems to be safe and effective for outpatient therapy of patients with low-risk febrile neutropenia.

Economic evaluation of gemcitabine single agent therapy compared with standard treatment in stage IIIB and IV non-small cell lung cancer

Chemotherapy treatment of patients with advanced non-small cell lung cancer (NSCLC) has been characterised by low cure rates, serious side effects, and expensive inpatient care. The aim of the present report was to perform an economic evaluation of gemcitabine monotherapy compared with standard chemotherapy treatment for NSCLC stages IIIB and IV. Standard chemotherapy treatment was identified as cisplatin/etoposide and ifosfamide/etoposide. Effectiveness expressed as survival and tumour response rates was assumed to be broadly equivalent for the alternatives. A cost-minimisation analysis was therefore performed. Total costs per patient per first treatment cycle of chemotherapy for the alternatives cisplatin/etoposide, ifosfamide/etoposide and gemcitabine were Skr 15,131, Skr 25,226, and Skr 13,266, respectively. The results are sensitive to whether chemotherapy could be given in inpatient or in outpatient care. Monotherapy with gemcitabine outpatient treatment in patients with stage IIIB and IV NSCLC was found to be a cost saving alternative when compared with currently used inpatient combination regimens. The treatment alternative with gemcitabine appears to be associated with higher costs for drugs and outpatient care, but lower costs for inpatient care and treatment of adverse events.

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.

Investigation of infection in the neutropenic patient with fever

Episodes of infection occurring in neutropenic patients are often associated with high levels of morbidity and mortality and prompt, accurate diagnosis allowing the rapid instigation of appropriate treatment can lead to an improved outcome. Recent developments in laboratory technology have increased the range of investigations available to the physician. The improved sensitivity of traditional microbiological culture, methods for antigen and antibody detection and the advances in molecular biology are among the reasons for an increased ability to detect both familiar and novel pathogens. This article describes the current methods available for determining the aetiology of an infectious episode in these patients. A plan of management for investigation of febrile episodes in neutropenic patients is suggested.

Low-risk febrile neutropenia in a medical oncology unit

BACKGROUND

Febrile neutropenia occurring in patients receiving chemotherapy for solid tumours or lymphoma is usually of short duration, and therefore may have a better outcome compared to patients with acute leukaemia or patients receiving myeloablative chemotherapy.

AIMS

To review retrospectively the outcomes for febrile neutropenia occurring in patients of the Medical Oncology Unit at our institution, and to identify factors associated with worse outcome, particularly prolonged admission or death.

METHODS

We reviewed 102 episodes of febrile neutropenia occurring in 85 patients treated between 1992 and 1994. Demographic factors, tumour-related factors and clinical aspects of the episodes were correlated with outcome.

RESULTS

The median age was 60 years (range, 18-87), with 56 (55%) episodes occurring in females. Twenty-eight (27%) episodes occurred in patients with lymphoma, with the remaining 74 (73%) occurring in patients with solid tumours. At presentation, the median absolute neutrophil count (ANC) was 0.14 x 10(9)/L with a median duration of significant neutropenia (ANC < 0.5 x 10(9)/L) of three days. The median duration of fever was two days. Twenty-nine (28%) episodes had positive cultures; of these 11 had bacteraemia. Forty-four (43%) episodes were classified as unexplained fevers. The remaining 29 episodes were associated with clinically documented infection but negative cultures. There was a high treatment success rate (81%) with first-line empirical antibiotics. Of 19 treatment failures, 13 were due to the necessity for antibiotic modification; the other six patients died from infection. Factors associated with a worse outcome (including prolonged admission and death) include: diagnosis of lymphoma; increasing number of chemotherapy courses; early onset of neutropenia; pneumonia; severe hypotension; and multiple co-morbidities.

CONCLUSIONS

Febrile neutropenia in adult patients with solid tumours or lymphoma is associated with a relatively good outcome, possibly due to the short duration of neutropenia. A future prospective study to validate the risk factors identified in this study would be useful for defining patients at low risk for the adverse outcomes examined, in whom less intensive management for this condition may be possible.

Ceftazidime and ciprofloxacin as empiric therapy in febrile neutropenic patients undergoing hematopoietic stem cell transplantation

This pilot study was done to assess the efficacy and toxicity of intravenous ceftazidime and ciprofloxacin in patients developing febrile neutropenia while undergoing high-dose myeloablative therapy and hematopoietic stem cell transplantation (HSCT). All patients undergoing high-dose chemoradiotherapy and HSCT for leukemias, lymphomas, multiple myeloma, and solid tumors received open-label ceftazidime 2 g intravenously every 8 hours and ciprofloxacin 400 mg intravenously every 12 hours if they developed fever while they were neutropenic. Success with or without modification of this regimen was defined as survival through the neutropenic period; failure was defined as death secondary to infection. Among 45 patients treated with this regimen, the success rate was 98%. Sixty-two percent (28 of 45) of the patients achieved defervescence within 48 to 72 hours and remained afebrile without regimen modification. In 16 patients (36%) the regimen was modified because of persistent fever. The combination of ceftazidime and ciprofloxacin as initial empiric antibacterial therapy in febrile neutropenic patients undergoing myeloablative therapy and HSCT appears to be highly effective and is associated with minimal toxicity.

Once daily ceftriaxone plus amikacin vs. three times daily ceftazidime plus amikacin for treatment of febrile neutropenic children with cancer. Writing Committee for the International Collaboration on Antimicrobial Treatment of Febrile Neutropenia in Children

BACKGROUND

The combination of ceftazidime plus aminoglycoside is widely used for the treatment of febrile neutropenic patients but requires multiple daily administration. Because the frequency of Pseudomonas aeruginosa is low in many centers, there is a rationale to test other antibiotic regimens that provide appropriate antibacterial coverage with the advantage of reduced dosing frequency, such as once daily ceftriaxone plus amikacin.

METHODS

Febrile neutropenic children with leukemia, lymphoma or solid tumors after chemotherapy were included in an open, prospective, randomized, multinational study comparing once daily ceftriaxone plus amikacin vs. 8-hourly ceftazidime and amikacin. The response to antimicrobial therapy was defined as complete response, improvement or failure. Assessment of adverse events was supplemented by specific definitions of nephrotoxicity, ototoxicity, hepatotoxicity and hypokalemia. Costs were estimated from published values of acquisition costs, delivery costs and hospitalization costs.

RESULTS

Efficacy was evaluable in 364 of 468 episodes in 265 children. Response rates in ceftriaxone and amikacin vs. ceftazidime and amikacin-treated episodes were 119 of 181 (66%) vs. 121 of 183 (66%), 7 of 181 (4%) vs. 9 of 183 (5%) and 55 of 181 (30%) vs. 53 of 181 (29%) for complete response, improvement and failure, respectively. Safety profiles were similar with both treatment regimens. The acquisition and administration costs were lower for the ceftriaxone and amikacin regimen.

CONCLUSIONS

A once daily regimen of ceftriaxone and amikacin is as safe and clinically effective as that of three times daily ceftazidime and amikacin for the treatment of febrile neutropenic children with cancer and is more cost-effective. The once daily regimen of ceftriaxone and amikacin is suitable for outpatient treatment.

Chemotherapy-induced neutropenia and fever in patients with metastatic breast carcinoma receiving salvage chemotherapy

BACKGROUND

Chemotherapy-induced neutropenia and associated fever and infection are the most common complications of systemic chemotherapy. In this retrospective analysis, the authors evaluated the incidence of neutropenic fever, infection, and mortality in relation to the level of neutropenia, performance status, course number of chemotherapy, bone marrow metastasis, and age among patients with metastatic breast carcinoma receiving salvage chemotherapy.

METHODS

A total of 174 patients with previously treated metastatic breast carcinoma enrolled on 4 consecutive Phase II protocols were evaluated.

RESULTS

Twenty-three percent of the patients had an episode of neutropenic fever (41 episodes among 40 patients). The incidence of neutropenic fever did not increase until the absolute neutrophil count (ANC) had decreased to less than 500/microL, and then fever incidence had a linear relationship with decreasing ANC (linear trend, P < 0.01). A source of infection was documented in 59% of the neutropenic fever episodes. The incidence of infection did not increase significantly until the ANC had decreased to less than 250/microL (P < 0.01). The risk of neutropenic fever and infection was also significantly higher when patients had poor performance status or were undergoing the initial courses of chemotherapy. Patients with bone marrow metastases also had a higher frequency of fever, infection, and death, but these differences were not statistically significant.

CONCLUSIONS

For patients with metastatic breast carcinoma receiving salvage chemotherapy, the risk of fever increases with decreasing ANC, but the risk of infection does not increase significantly until ANC decreases to less than 250/microL. Poor performance status, initial courses of chemotherapy, and bone marrow metastases further increase the risk of fever, infection, and death.

Outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer

Until recently, febrile neutropenic patients were treated with intravenous antibiotics in inpatient settings. Because of work completed in the last several years by various investigators, identification of a low-risk group of febrile, neutropenic patients has allowed successful treatment with both parenteral and oral antibiotics in an ambulatory environment. This accomplishment has been facilitated by advances in broad-spectrum antibiotics with long half-lives and stabilities, the introduction of the quinolones providing oral antipseudomonal activity, home health care, improvements in vascular access devices, and technically enhanced antibiotic delivery systems. This review focuses on the rationale of risk stratification and the progress made in treating low-risk febrile neutropenic patients as outpatients.

Use of fluoroquinolones for empirical management of febrile neutropenia in pediatric cancer patients

BACKGROUND

Empiric antibiotic therapy has become a standard of care for the febrile neutropenic patient. Many clinical trials over the previous three decades have demonstrated that a variety of antibiotic combinations and more recently potent antibiotic monotherapies may preserve the patient through the critical time of fever and neutropenia. Recently attempts have been made to identify "low risk" patients who may not require traditional, intensive, hospitalized intravenous antimicrobial therapy. Therefore the need for new treatment alternatives for the febrile neutropenic pediatric cancer patient in particular revolves around the desire for less complex regimens, agents with minimal toxicity and expense and the option of an oral formulation for outpatient management.

OBJECTIVE

Fluoroquinolones, especially ciprofloxacin and ofloxacin, are examined in this paper as potential oral alternatives for managing the low risk neutropenic pediatric cancer patient population. Attention must be paid to their antibacterial spectra, however, and in some cases fluoroquinolones should be combined with a second agent for additional Gram-positive coverage.

RESULTS

Several studies, including one ongoing trial at the National Cancer Institute, have shown the potential benefits of oral fluoroquinolone therapy among low risk febrile neutropenic patients. Joint complaints in children after ciprofloxacin therapy in the National Cancer Institute trial thus far have been minimal, reversible and felt to be unrelated to ciprofloxacin treatment.

CONCLUSION

The use of outpatient therapy, such as the fluoroquinolones, to manage febrile neutropenic episodes must be approached with caution and should be undertaken only in selected low risk patients.

Intravenous antimicrobial therapy in the community: underused, inadequately resourced, or irrelevant to health care in Britain?

The NHS Executive is keen to promote "hospital at home" services in Britain, as part of its philosophy of keeping more care in the community and also to relieve the increasing demand for hospital beds. One such service is the provision of intravenous antimicrobial therapy in the community. Yet, compared with the United States, where home or outpatient intravenous antimicrobial therapy programmes are well developed, experience in Britain and Europe is limited, reflecting a difference in cultural attitudes and healthcare structures between the two continents. Only a few units in Britain currently run home intravenous antimicrobial therapy programmes, and several issues need to be addressed if more treatment is to be provided outside hospital. These include an assessment of the need for community intravenous antibiotic treatment and which patient groups many benefit. The main motive for community intravenous treatment should be better patient care and not simply a reduction in healthcare costs. At present the pace of change is being set by a few clinical enthusiasts and by commercial organisations, whereas the NHS deserves a more organised strategy for purchasing treatment with intravenous antibiotics in the community.

Fever in the neutropenic host

Fever in the neutropenic patient following myelosuppressive chemotherapy is a medical emergency. Appropriate antimicrobial therapy can dramatically reduce infection-related morbidity and mortality. This article reviews the rationale and methodology of treatment as well as its applicability to other neutropenic states. The utility of adjunct therapy with granulocyte- stimulating compounds is also discussed.

Stepdown single agent antibiotic therapy for the management of the high risk neutropenic adult with hematologic malignancies

The standard of therapy for the high risk adult neutropenic host being treated with broad spectrum antibiotics for fever has been to continue intravenous antibiotics until neutropenia resolves. We performed a small, limited pilot study to determine if it is safe to switch these patients to oral monotherapy with ciprofloxacin. Ten patients with hematologic malignancies who had < or = 108 granulocytes/mm3 after cytoreductive therapy and were afebrile for at least five days had intravenous antibiotics discontinued and were placed on oral ciprofloxacin. Eight patients were able to be discharged from the hospital and seven were treated without the need for reinstitution of intravenous therapy. Of the three failures, one developed fever with a new bloodstream infection and two developed fever with relapse of leukemia. Patients remained on ciprofloxacin an average of 14.5 days (range 4 to 35 days). Aggregate cost savings for the 10 patients from this approach were estimated to be $11,400 for antibiotics and $88,800 for hospitalization. If corroborated in larger, randomized studies, the use of "stepdown monotherapy" may be a cost effective approach to the management of the stable neutropenic patient.

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.

Clinical role of GM-CSF in neutrophil recovery in relation to health care parameters

Recombinant growth factors, particularly granulocyte-macrophage colony-stimulating factor (GM-CSF), have been only available for a few years. Since their introduction they have affected the management of drug-induced neutropenia, the use of dose intensive chemotherapy regimens and in the setting of autologous stem cell transplantation. This review addresses the clinical role of GM-CSF, using the data available, in neutrophil recovery in relation to various health care parameters.

Early empiric antibiotic therapy for febrile neutropenia patients at low risk

Although it is apparent that certain patients with febrile neutropenic episodes can benefit from outpatient antibiotic therapy, not all low-risk patients are treated in this fashion. There are barriers, real and perceived, to implementing this approach for patients, health care providers, and caregivers. Table 3 summarizes the advantages and disadvantages of ambulatory management of febrile neutropenic patients. For many patients and physicians, outpatient oral antibiotics may be preferred, whereas for others a more conservative approach might be needed in order to feel comfortable with treating this population on an outpatient basis. In this situation, patients can be treated in a stepwise fashion as shown in Table 4. These alternatives allow physicians and patients options to discuss when planning treatment strategies for febrile neutropenia.

Current Approach to the Management of Neutropenia

Neutrophils have a critical role in host defense. Reduction in the absolute neutrophil count to below 1,000/μL is associated with increased susceptibility to infection. The pattern of infections depends on the severity and the duration of neutropenia and other associated defects in host defense mechanisms and exposure to antibiotics and other drugs, particularly corticosteroids and immunosuppressive agents. Breaks in the integrity of the skin or the gastrointestinal mucosal surfaces serve as the portals of entry for the majority of infecting organisms. Empiric antibiotic therapy and hospitalization are almost always required for the management of fever (temperature >38.2°C) in a neutropenic patient. A single antibiotic (e.g., ceftazidime or imipenem) or a combination of antibiotics with activity against both gram-positive and gram-negative organisms usually provides effective antimicrobial therapy. In low-risk patients, trials of out-patient therapy are ongoing. When febrile neutropenia does not respond to empiric broad-spectrum antibacterial therapy, fungal infections, particularly Candida and Aspergillus, should be considered, and antifungal therapy should be initiated. Recently, availability of the hematopoietic growth factors, particularly G-CSF and GM-CSF, have changed the approach to prevention and treatment of neutropenia. Randomized controlled studies have established that these growth factors accelerate hematopoietic recovery following chemotherapy and bone marrow transplantation. By shortening the duration of neutropenia, many of the heretofore inevitable problems with fever and infection can be avoided. The only major factor limiting the use of these agents is their cost. Despite the use of these growth factors, some patients will still experience slow hematopoietic recovery. For these patients, use of neutrophil transfusions, possibly from G-CSF-stimulated normal donors, may prove to be a useful adjunctive therapy.