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Leloch DE. Assessment and management of adult patients with neutropenic sepsis in the emergency department. Emerg Nurse 2023; 31:22-26. [PMID: 36794510 DOI: 10.7748/en.2023.e2159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 02/17/2023]
Abstract
As cancer diagnoses rise, and more treatment options become available, doctors, nurses and allied health professionals will increasingly encounter more patients with acute oncological emergencies in the emergency department (ED). Neutropenia (low levels of neutrophils in the blood) is a common side effect of systemic anti-cancer therapy, particularly chemotherapy, and has a negative effect on patients' immune system, leaving them vulnerable to infection. Patients who develop neutropenia are at increased risk of developing neutropenic sepsis, a potentially life-threatening condition that requires urgent assessment and treatment within an hour of presentation. This article describes the risk factors for and signs and symptoms of neutropenic sepsis and outlines assessment and management of patients who present to the ED with this condition.
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RODRIGUES I, NASCIMENTO L, PIMENTA AC, RAIMUNDO S, CONDE B, FERNANDES A. [Neutropenic Fever in Lung Cancer: Clinical Aspects Related to Mortality and Antibiotic Failure]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2021; 24:764-769. [PMID: 34802207 PMCID: PMC8607283 DOI: 10.3779/j.issn.1009-3419.2021.102.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lung cancer (LC) is the leading cause of cancer death. Patients treated with chemotherapy are at risk of developing chemotherapy-induced febrile neutropenia (FN), a potentially life-threatening complication. The aims of this study were (1) to characterize FN admissions of patients with LC in a pulmonology department, and (2) to determine associations between patient profiles, first-line antibiotic failure (FLAF) and mortality. METHODS Retrospective observational case-series, based on the analysis of medical records of LC patients that required hospitalization due to chemotherapy-induced FN. RESULTS A total of 42 cases of FN were revised, corresponding to 36 patients, of which 86.1% were male, with a mean age of 66.71±9.83 years. Most patients had a performance status (PS) equal or less than 1, and metastatic disease was present in 40.5% (n=17). Respiratory tract infections accounted for 42.9% (n=18) of FN cases, and multidrug-resistant Staphylococcus aureus was the most isolated agent. The mortality rate was 16.7% (n=7), and the FLAF was 26.2% (n=11). Mortality was associated with a PS≥2 (P=0.011), infection by a Gram-negative agent (P=0.001) and severe anemia (P=0.048). FLAF was associated with longer hospitalizations (P=0.020), PS≥2 (P=0.049), respiratory infections (P=0.024), and infection by a Gram-negative (P=0.003) or multidrug-resistant agent (P=0.014). CONCLUSIONS Lower PS, severe anemia, and infections by Gram-negative or multi-resistant agents seem to be associated with worse outcomes in FN patients.
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Affiliation(s)
- Inês RODRIGUES
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal,Inês RODRIGUES, E-mail:
| | - Luísa NASCIMENTO
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Ana Cláudia PIMENTA
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Sara RAIMUNDO
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Bebiana CONDE
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Ana FERNANDES
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
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Risk Stratification and Management of Febrile Cancer Patients: Australian Perspective. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wijeratne DT, Wright K, Gyawali B. Risk-Stratifying Treatment Strategies for Febrile Neutropenia-Tools, Tools Everywhere, and Not a Single One That Works? JCO Oncol Pract 2021; 17:651-654. [PMID: 33914611 DOI: 10.1200/op.21.00148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Kristin Wright
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
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Bhardwaj PV, Emmich M, Knee A, Ali F, Walia R, Roychowdhury P, Clark J, Sridhar A, Lagu T, Loh KP. Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study. Support Care Cancer 2021; 29:5905-5914. [PMID: 33761002 PMCID: PMC7987550 DOI: 10.1007/s00520-021-06154-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/15/2021] [Indexed: 01/21/2023]
Abstract
Purpose The Multinational Association for Supportive Care in Cancer (MASCC) score is used to risk stratify outpatients with febrile neutropenia (FN). However, it is rarely used in hospital settings. We aimed to describe management, use of MASCC score, and outcomes among hospitalized patients with FN. Methods We conducted a retrospective cohort study of patients with cancer and FN. We collected patient demographics, cancer characteristics, microbiological profile, MASCC score, utilization of critical care therapies, documentation of goals of care (GOC), and inpatient deaths. Outcomes associated with low- (≥ 21) versus high-risk (< 21) MASCC scores are presented as absolute differences. Results Of 193 patients, few (2%, n = 3) had MASCC scores documented, but when calculated, 52% (n = 101) had a high-risk score (< 21). GOC were discussed in 12% (n = 24) of patients. Twenty one percent (n = 40) required intermediate/ICU level of care, and 12% (n = 23) died in the hospital. Those with a low-risk score were 33% less likely to require intermediate/ICU care (95% CI 23 to 44%) and 19% less likely to die in the hospital (95% CI 10% to 27%) compared to those with high-risk score. Conclusions MASCC score was rarely used for hospitalized patients with FN, but high-risk score was associated with worse outcomes. Education efforts to incorporate MASCC score into the workflow may help identify patients at high risk for complications and help clinicians admit these patients to a higher level of care (e.g., intermediate/ICU care) or guide them to initiate earlier GOC discussions.
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Affiliation(s)
- Prarthna V. Bhardwaj
- Division of Hematology Oncology, University of Massachusetts Medical School-Baystate, 759 Chestnut St, Springfield, MA 01199 USA
| | - Megan Emmich
- Division of Hematology Oncology, University of Connecticut, Farmington, CT USA
| | - Alexander Knee
- Office of Research, Epidemiology/Biostatistics Research Core, Baystate Medical Center, Springfield, MA USA
| | - Fatima Ali
- Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Ritika Walia
- Department of Medicine-Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | | | - Jackson Clark
- Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Arthi Sridhar
- Division of Hematology Oncology, University of Texas at Houston, Houston, TX USA
| | - Tara Lagu
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, IL USA
- Division of Hospital Medicine, Northwestern Feinberg School of Medicine, Chicago, IL USA
| | - Kah Poh Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY USA
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Zheng B, Toarta C, Cheng W, Taljaard M, Reaume N, Perry JJ. Accuracy of the Multinational Association of Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for predicting serious complications in adult patients with febrile neutropenia: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2020; 149:102922. [DOI: 10.1016/j.critrevonc.2020.102922] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/27/2019] [Accepted: 03/02/2020] [Indexed: 11/17/2022] Open
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Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department. PLoS One 2020; 15:e0229828. [PMID: 32109264 PMCID: PMC7048306 DOI: 10.1371/journal.pone.0229828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/16/2020] [Indexed: 01/26/2023] Open
Abstract
Introduction The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED. Methods We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses. Results We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28). Conclusion An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.
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A multicenter prospective study of 515 febrile neutropenia episodes in Argentina during a 5-year period. PLoS One 2019; 14:e0224299. [PMID: 31671108 PMCID: PMC6822758 DOI: 10.1371/journal.pone.0224299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/09/2019] [Indexed: 12/27/2022] Open
Abstract
For better management of patients with febrile neutropenia, our study investigated the epidemiologic, microbiologic, and clinical characteristics of adult inpatients with febrile neutropenia and their mortality-associated factors. To this end, we carried out a prospective, observational, multicenter study in 28 Argentinian hospitals between 2007 and 2012. We included 515 episodes of febrile neutropenia from 346 patients, median age 49 years. Neutropenia followed chemotherapy in 77% of cases, half of the cases due to hematological malignancies. Most episodes were classified as high-risk according to MASCC criteria, and 53.6% of patients were already hospitalized at the onset of febrile neutropenia. Bloodstream infections were detected in 14% episodes; whereas an infectious source of fever was identified in 80% of cases. Mortality rate achieved to 14.95%. The binary regression analysis showed that persistence of fever at day 7, or neutropenia at day 14, dehydration and tachycardia at the onset of febrile neutropenia as well as prior infections were significantly associated with mortality. In addition to expanding our current knowledge on the features of adult patients with febrile neutropenia, present findings provide useful information for better management of them in Argentina, given the appropriate representativeness of centers participating in the study.
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Long B, Koyfman A. Oncologic Emergencies: The Fever With Too Few Neutrophils. J Emerg Med 2019; 57:689-700. [PMID: 31635928 DOI: 10.1016/j.jemermed.2019.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/10/2019] [Accepted: 08/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cancer is associated with a variety of complications, including neutropenic fever, which can result in severe morbidity and mortality. This oncologic emergency requires ED management. OBJECTIVE This narrative review provides focused updates for emergency clinicians regarding neutropenic fever. DISCUSSION Neutropenic fever is defined by fever with oral temperature >38.3°C or temperature >38.0°C for 1 hour with an absolute neutrophil count (ANC) < 1000 cells/microL. Patients who have received chemotherapy within 6 weeks of presentation are at high risk for neutropenia. While most patients with neutropenic fever do not have an identifiable bacterial source of fever, clinicians should treat patients for bacterial infection. Rapid assessment and management are vital to improving outcomes in patients with suspected or confirmed neutropenic fever. History and examination should focus on the most common sites of infection: the gastrointestinal tract, blood, skin, lung, and urinary tract. However, physical examination and laboratory or imaging assessment may not display classic signs of infection. Blood cultures should be obtained, and broad-spectrum antibiotics are recommended. Oncology consultation is an integral component in the care of these patients. Several risk scores can assist in stratifying patients who may be appropriate for discharge home and follow-up. CONCLUSIONS Neutropenic fever is an oncologic emergency. Rapid diagnosis and care of patients with neutropenic fever can improve outcomes, along with oncology consultation.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Moon H, Choi YJ, Sim SH. Validation of the Clinical Index of Stable Febrile Neutropenia (CISNE) model in febrile neutropenia patients visiting the emergency department. Can it guide emergency physicians to a reasonable decision on outpatient vs. inpatient treatment? PLoS One 2018; 13:e0210019. [PMID: 30596803 PMCID: PMC6312365 DOI: 10.1371/journal.pone.0210019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/14/2018] [Indexed: 11/23/2022] Open
Abstract
Advances in oncology have enabled physicians to treat low-risk febrile neutropenia (FN) in outpatient settings. This study was aimed to explore the usefulness of the CISNE model and identify better triage in the emergency setting. This is a retrospective cohort study on 400 adult FN patients presenting to the Emergency Department of National Cancer Center, Korea from January 2010 to December 2016. All had been treated with cytotoxic chemotherapy for solid tumors in the previous 30 days. The primary outcome was the frequency of any serious complications during the duration of illness. Apparently stable patients numbered 299 (74.8%) of 400, and the remainder comprised clinically unstable patients. The stable patients fell into three cohorts according to the risk scores: CISNE I (low risk), 56 patients (18.7%); CISNE II (intermediate), 124 (41.5%) and CISNE III (high), 119 (39.8%). The primary outcome occurred in 10.7%, 19.4% and 33.6%, respectively, according to the cohort. Compared with the Multinational Association of Supportive Care in Cancer Risk Index Score (MASCC RIS), CISNE I stratum had significantly lower sensitivity (0.22 vs. 0.95 of MASCC low risk) but higher specificity (0.91 vs. 0.17) to predict zero occurrence of the primary outcome. The CISNE model was useful for identifying low-risk FN patients for outpatient treatment. The combination of the CISNE and MASCC RIS may help emergency physicians cope with FN more confidently.
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Affiliation(s)
- Hae Moon
- Department of Internal Medicine, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
| | - Young Ju Choi
- Infectious Diseases Clinic, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
| | - Sung Hoon Sim
- Center for Breast Cancer, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
- Translational Cancer Research Branch, Division of Cancer Biology, Research Institute, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
- * E-mail:
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Warnock C, Totterdell P, Tod AM, Mead R, Gynn JL, Hancock B. The role of temperature in the detection and diagnosis of neutropenic sepsis in adult solid tumour cancer patients receiving chemotherapy. Eur J Oncol Nurs 2018; 37:12-18. [PMID: 30473045 DOI: 10.1016/j.ejon.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE The primary aim of this study was to examine the value of temperature as a diagnostic and prognostic indicator of infection and sepsis in neutropenic patients. A secondary aim was to gain insight into the presenting symptoms reported by these patients at home or on their initial admission assessment. METHODS A cohort study was carried out using a case note review of 220 emergency admissions to a regional cancer centre. All participants were neutropenic and were diagnosed with infection on admission. The main outcome measures were relationships between Early Warning Scores and temperature values at home, on admission and during the hospital stay. RESULTS 22% of patients who became acutely unwell did not have a fever. Pearson correlations showed only small associations between highest temperature value at any time point and highest early warning scores (r(202) = 0.176, P = .012). Temperature at home (B = 0.156, P = .336) and temperature on admission (B = 0.200, P = .052) did not predict highest Early Warning Scores. CONCLUSIONS Body temperature is not a consistently reliable diagnostic or prognostic indicator for outcomes in patients with neutropenia and symptoms of infection. It can assist with early presentation and recognition of infection in many neutropenic patients. However, over-reliance on temperature risks missing the opportunity for early detection and treatment.
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Affiliation(s)
- Clare Warnock
- Weston Park Hospital, Specialist Cancer Services, Sheffield Teaching Hospitals NHS Foundation Trust, Witham Road, Sheffield, S10 2SJ, UK.
| | - Peter Totterdell
- University of Sheffield, Cathedral Court, 1, Vicar Lane, Sheffield, S1 2LT, UK.
| | - Angela Mary Tod
- University of Sheffield, Barber House Annexe, 3a, Clarkehouse Road, Sheffield, S10 2LA, UK.
| | - Rachel Mead
- Weston Park Hospital, Specialist Cancer Services, Sheffield Teaching Hospitals NHS Foundation Trust, Witham Road, Sheffield, S10 2SJ, UK
| | - Jamie-Lee Gynn
- Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, Derbyshire, S44 5BL, UK
| | - Barry Hancock
- University of Sheffield, Weston Park Hospital, Witham Road, Sheffield, S10 2SJ, UK
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Charshafian S, Liang SY. Rapid Fire: Infectious Disease Emergencies in Patients with Cancer. Emerg Med Clin North Am 2018; 36:493-516. [PMID: 30037437 DOI: 10.1016/j.emc.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with cancer can be immunocompromised because of their underlying malignancy as well as the medical therapies with which they are treated. Infections frequently present atypically and can be challenging to diagnose. The spectrum of infectious diseases encountered in patients receiving chemotherapy, hematopoietic stem cell transplant, and immunotherapy is broad depending on the depth of immunosuppression. Early recognition of infectious processes followed by appropriate diagnostic testing, imaging, and empiric antibiotic therapy in the emergency department are critical to providing optimal care and improving survival in this complex patient population.
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Affiliation(s)
- Stephanie Charshafian
- Division of Emergency Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8072, St Louis, MO 63110, USA
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110, USA.
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Carmona-Bayonas A, Jiménez-Fonseca P. CISNE or MASCC, which predictor is really the weakest in febrile neutropenia? Eur J Intern Med 2018; 50:e33-e34. [PMID: 29157884 DOI: 10.1016/j.ejim.2017.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 11/19/2022]
Affiliation(s)
- A Carmona-Bayonas
- Hematology & Medical Oncology Department, Hospital Universitario Morales Meseguer, Murcia, Spain.
| | - P Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
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A cohort study on protocol-based nurse-led out-patient management of post-chemotherapy low-risk febrile neutropenia. Support Care Cancer 2018; 26:3039-3045. [PMID: 29556814 DOI: 10.1007/s00520-018-4157-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE International guidelines adopt risk stratification approach to manage patients with low-risk febrile neutropenia patients. We developed this out-patient program using shared-care model with professional input and patient empowerment, so as to reduce patients' psychological burden from hospitalization and to improve the cost-effectiveness of management. METHOD This is a prospective cohort study to compare the efficacy and safeness of the out-patient program when compared with traditional in-patient care. Patients with solid tumors, developed febrile neutropenia with Multinational Association of Supportive Care in Cancer score of at least 21, and good performance status were included. After initial assessment and the first dose of oral antibiotics, patients were observed in the ambulatory center. Stable patients were discharged home after 4 h of observation and nurse counseling. Patients' condition and clinical progress were regularly reviewed by specialist nurses within the following week by telephone and nurse clinic follow-up. The primary objective of the study is success rate, which defined as the resolution of fever and infection, without hospitalization or any change in antibiotics. RESULTS From September 2014 to December 2016, a total of 38 patients were enrolled. Majority were female with breast cancer (97%). Two patients required hospitalization due to persistent fever. The success rate of the out-patient program was not significantly different from the historical in-patient cohort (94.9 versus 97.4%, p = 0.053). No mortality was observed. Patients' compliance to the program was 100%, to telephone follow-up, nurse clinic visits, and daily temperature record. CONCLUSION Out-patient management of patients with low-risk febrile neutropenia is effective and safe through implementation of a structured protocol with joint inputs and engagement from clinicians, oncology nurses, and patients.
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De Silva N, Jackson J, Steer C. Infections, resistance patterns and antibiotic use in patients at a regional cancer centre. Intern Med J 2018; 48:323-329. [DOI: 10.1111/imj.13646] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Nivanka De Silva
- Faculty of Medicine; University of New South Wales (UNSW) Rural Clinical School; Albury Campus, Albury New South Wales Australia
| | - Justin Jackson
- Faculty of Medicine; University of New South Wales (UNSW) Rural Clinical School; Albury Campus, Albury New South Wales Australia
- Albury Wodonga Health; Albury New South Wales Australia
| | - Christopher Steer
- Faculty of Medicine; University of New South Wales (UNSW) Rural Clinical School; Albury Campus, Albury New South Wales Australia
- Albury Wodonga Health; Albury New South Wales Australia
- Border Medical Oncology; Albury Wodonga Regional Cancer Centre; Albury New South Wales Australia
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Rationale and design of DUAL study: Doxycycline to Upgrade response in light chain (AL) amyloidosis (DUAL): A phase 2 pilot study of a two-pronged approach of prolonged doxycycline with plasma cell-directed therapy in the treatment of AL amyloidosis. Contemp Clin Trials Commun 2017; 8:33-38. [PMID: 29696194 PMCID: PMC5898504 DOI: 10.1016/j.conctc.2017.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 12/19/2022] Open
Abstract
Light chain (AL) amyloidosis is a plasma cell neoplasm associated with insoluble fibril deposition from clonal immunoglobulin chains systemically. The disease is associated with high early mortality and morbidity owing to advanced organ deposition as well as lack of proven de-fibrillogenic therapies. Pre-clinical and retrospective clinical data suggests that doxycycline has benefit in AL amyloidosis. The ongoing DUAL study is a single center, open label, phase 2 study in which patients with AL amyloidosis who are undergoing clone-directed therapy for the underlying neoplasm with oral doxycycline given for 1 year to test the hypothesis that prolonged doxycycline use will be safe, feasible, and lead to reduced early mortality in systemic AL amyloidosis and hasten organ amyloid response. Clinical follow up visits will occur at monthly intervals for systemic AL patients and at 3 monthly intervals for localized AL patients. Blood tests will be collected during these time points for hematologic response assessment. Organ testing will be conducted at 3 monthly intervals and radiologic testing will be conducted at 6 monthly intervals. Research blood samples will be collected at baseline, 6 and 12 months. Other correlative studies include matrix metalloproteinases (MMP), tissue inhibitor of metalloproteinases (TIMP) testing and patient-reported outcomes.
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The time has come for new models in febrile neutropenia: a practical demonstration of the inadequacy of the MASCC score. Clin Transl Oncol 2017; 19:1084-1090. [PMID: 28289961 DOI: 10.1007/s12094-017-1644-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/04/2017] [Indexed: 10/20/2022]
Abstract
Since its publication more than 15 years ago, the MASCC score has been internationally validated any number of times and recommended by most clinical practice guidelines for the management of febrile neutropenia (FN) around the world. We have used an empirical data-supported simulated scenario to demonstrate that, despite everything, the MASCC score is impractical as a basis for decision-making. A detailed analysis of reasons supporting the clinical irrelevance of this model is performed. First, seven of its eight variables are "innocent bystanders" that contribute little to selecting low-risk candidates for ambulatory management. Secondly, the training series was hardly representative of outpatients with solid tumors and low-risk FN. Finally, the simultaneous inclusion of key variables both in the model and in the outcome explains its successful validation in various series of patients. Alternative methods of prognostic classification, such as the Clinical Index of Stable Febrile Neutropenia, have been specifically validated for patients with solid tumors and should replace the MASCC model in situations of clinical uncertainty.
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Klastersky J, de Naurois J, Rolston K, Rapoport B, Maschmeyer G, Aapro M, Herrstedt J. Management of febrile neutropaenia: ESMO Clinical Practice Guidelines. Ann Oncol 2016; 27:v111-v118. [PMID: 27664247 DOI: 10.1093/annonc/mdw325] [Citation(s) in RCA: 400] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- J Klastersky
- Institut Jules Bordet-Centre des Tumeurs de l'ULB, Brussels, Belgium
| | - J de Naurois
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - K Rolston
- M.D. Anderson Cancer Center, Houston, TX, USA
| | - B Rapoport
- Medical Oncology Centre of Rosebank, Johannesburg, South Africa
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst von Bergmann Hospital, Potsdam, Germany
| | - M Aapro
- Multidisciplinary Institute of Oncology, Clinique de Genolier, Genolier, Switzerland
| | - J Herrstedt
- Department of Oncology, Odense University Hospital (OUH), Odense, Denmark
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Klastersky J, Paesmans M, Aoun M, Georgala A, Loizidou A, Lalami Y, Dal Lago L. Clinical research in febrile neutropenia in cancer patients: Past achievements and perspectives for the future. World J Clin Infect Dis 2016; 6:37-60. [DOI: 10.5495/wjcid.v6.i3.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 12/02/2015] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
Febrile neutropenia (FN) is responsible for significant morbidity and mortality. It can also be the reason for delaying or changing potentially effective treatments and generates substantial costs. It has been recognized for more than 50 years that empirical administration of broad spectrum antibiotics to patients with FN was associated with much improved outcomes; that has become a paradigm of management. Increase in the incidence of microorganisms resistant to many antibiotics represents a challenge for the empirical antimicrobial treatment and is a reason why antibiotics should not be used for the prevention of neutropenia. Prevention of neutropenia is best performed with the use of granulocyte colony-stimulating factors (G-CSFs). Prophylactic administration of G-CSFs significantly reduces the risk of developing FN and consequently the complications linked to that condition; moreover, the administration of G-CSF is associated with few complications, most of which are not severe. The most common reason for not using G-CSF as a prophylaxis of FN is the relatively high cost. If FN occurs, in spite of prophylaxis, empirical therapy with broad spectrum antibiotics is mandatory. However it should be adjusted to the risk of complications as established by reliable predictive instruments such as the Multinational Association for Supportive Care in Cancer. Patients predicted at a low level of risk of serious complications, can generally be treated with orally administered antibiotics and as out-patients. Patients with a high risk of complications should be hospitalized and treated intravenously. A short period of time between the onset of FN and beginning of empirical therapy is crucial in those patients. Persisting fever in spite of antimicrobial therapy in neutropenic patients requires a special diagnostic attention, since invasive fungal infection is a possible cause for it and might require the use of empirical antifungal therapy.
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Bitar RA. Utility of the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index Score as a Criterion for Nonadmission in Febrile Neutropenic Patients with Solid Tumors. Perm J 2016; 19:37-47. [PMID: 26176568 DOI: 10.7812/tpp/14-188] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile neutropenic episodes in patients with solid tumors were identified electronically from 10/1/2008 to 11/15/2010. Inclusion criteria were met in 198 episodes. Sensitivity, specificity, and positive and negative predictive values of the MASCC risk index score vs complications were, respectively, 94%, 29.6%, 57.7%, and 82.9%. An MASCC risk index score of 21 or greater could not be used as a criterion for "no complication/ do not admit." Inability to eat should be an admission criterion.
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Affiliation(s)
- Roger A Bitar
- Consultant with Mission Infectious Disease and Infusion Consultants, Inc, in Poway, CA, and a former Infectious Disease Specialist at the San Diego Medical Center.
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21
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Abdel-Rahman O, ElHalawani H, Essam-Eldin S. S-1-based regimens and the risk of leucopenic complications; a Meta-analysis with comparison to other fluoropyrimidines and non fluoropyrimidines. Expert Opin Drug Saf 2016; 15:437-48. [DOI: 10.1517/14740338.2016.1146674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Omar Abdel-Rahman
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hesham ElHalawani
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Shaimaa Essam-Eldin
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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22
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Penel-Page M, Normand C, Bertrand A, Levard A, Boyle H, Riberon C, Marec-Berard P. [Management of febrile neutropenias in adolescents and young adults: Differences of practice between adult and pediatric units]. Bull Cancer 2015; 102:915-22. [PMID: 26384690 DOI: 10.1016/j.bulcan.2015.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 07/15/2015] [Accepted: 08/04/2015] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Adolescents and young adults (AYA, 15-25years old) with cancer are treated either in adult or pediatric units. Management of febrile neutropenia (FN) is different between these units. Monitoring rules and indications of hospitalization are often stricter in pediatrics. This study evaluates if these differences influence the occurrence of complications. METHODS The medical records of AYA patients treated in our institution in the Euro-E-W-I-N-G99 protocol between 01/09/2000 and 31/05/2013 were retrospectively analyzed. We studied febrile neutropenias occurring after VIDE courses, during the induction period. RESULTS Forty-four patients were included (18 from adult units, 26 from pediatrics). Median age at inclusion was 19.6. After 260 courses of VIDE, we observed a median of 2 FN per adult and 3 per pediatric patient (P=0.2). Hospitalization occurred in median 1.5 time per adult and 3 per pediatric patient (P=0.008). Median cumulated length of stay was 4.5days for adults versus 16 days for pediatric patients (P=0.008). There was no significant difference for survival, number of documented infections, transfusions, dose modifications, chemotherapy delay, need for intensive care, infection after post-induction surgery. CONCLUSION AYA treated in adult services are less frequently hospitalized for FN with no difference in morbi-mortality. Homogeneous recommendations could be made for these patients, whatever the units they are treated in.
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Affiliation(s)
- Mathilde Penel-Page
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France; Université Claude-Bernard Lyon 1 69008 Lyon, France.
| | - Charline Normand
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France
| | - Amandine Bertrand
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France
| | - Alice Levard
- Centre Léon-Bérard (CLB), 28, rue Laennec, 69008 Lyon, France
| | - Helen Boyle
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France
| | - Christèle Riberon
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France
| | - Perrine Marec-Berard
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France; Université Claude-Bernard Lyon 1 69008 Lyon, France
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Klastersky JA, Meert AP. Understanding the risk for infection in patients with neutropenia. Intensive Care Med 2015; 42:268-70. [PMID: 26170099 DOI: 10.1007/s00134-015-3965-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/02/2015] [Indexed: 01/29/2023]
Affiliation(s)
- Jean A Klastersky
- Service de Médecine, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Rue Héger-Bordet 1, 1000, Brussels, Belgium.
| | - Anne-Pascale Meert
- Service des soins intensifs et urgences oncologiques et oncologie thoracique, Institut Jules Bordet, Rue Héger-Bordet 1, 1000, Brussels, Belgium
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Ahn S, Lee YS, Lee JL, Lim KS, Yoon SC. A new prognostic model for chemotherapy-induced febrile neutropenia. Int J Clin Oncol 2015; 21:46-52. [DOI: 10.1007/s10147-015-0853-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 05/23/2015] [Indexed: 11/28/2022]
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Pherwani N, Ghayad JM, Holle LM, Karpiuk EL. Outpatient management of febrile neutropenia associated with cancer chemotherapy: Risk stratification and treatment review. Am J Health Syst Pharm 2015; 72:619-31. [DOI: 10.2146/ajhp140194] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Nisha Pherwani
- Oncology, Cardinal Health, Innovative Delivery Solutions, Houston, TX
| | | | - Lisa M. Holle
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
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Ko BS, Ahn S, Lee YS, Kim WY, Lim KS, Lee JL. Impact of time to antibiotics on outcomes of chemotherapy-induced febrile neutropenia. Support Care Cancer 2015; 23:2799-804. [PMID: 25663578 DOI: 10.1007/s00520-015-2645-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/28/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE The aim of this study was to determine the relationship between the time to antibiotic administration and patients' outcomes of febrile neutropenia (FN). We also investigated the relationship between the time to antibiotics and mortality rates in a subgroup of patients with bacteremia or severe sepsis or septic shock. METHODS From the Neutropenic Fever Registry, we analyzed 1001 consecutive FN episodes diagnosed from November 1, 2011, to August 31, 2014. Timing cutoffs for antibiotics included the following: ≤1 vs. >1 h, ≤2 vs. >2 h, ≤3 vs. >3 h, and ≤4 vs. >4 h. Multivariate logistic regression was used to adjust for potential confounders in the association between timing intervals and outcomes of FN episodes. RESULTS The median length of time from triage to antibiotics was 140 min (interquartile range, 110-180 min). At each time cutoff, the time from triage to antibiotic administration was not significantly associated with FN outcomes after adjusting for potential confounders. Antibiotic timing was not significantly associated with complication rates in overall FN episodes. We failed to find a significant relationship between antibiotic timing and mortality in FN episodes with severe sepsis or septic shock or with bacteremia. Procalcitonin concentration and the Multinational Association for Supportive Care in Cancer (MASCC) risk index score were found to be more crucial determinants of outcomes in patients with FN. CONCLUSIONS The time to antibiotic administration is not a major factor in FN outcomes.
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Affiliation(s)
- Byuk Sung Ko
- Department of Emergency Medicine, Cancer Emergency Room, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
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Zhang S, Wang Q, Ling Y, Hu X. Fluoroquinolone resistance in bacteremic and low risk febrile neutropenic patients with cancer. BMC Cancer 2015; 15:42. [PMID: 25763661 PMCID: PMC4326398 DOI: 10.1186/s12885-015-1063-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/30/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The low risk febrile neutropenic patients with Multinational Association for Supportive Care in Cancer (MASCC) score of more than 20 are recommended to be treated with fluoroquinolone-based oral treatment by the National Comprehensive Cancer Network (NCCN) guideline. This recommendation relies, at least partially, on the high sensitivity of the blood culture isolates to fluoroquinolone in clinical trials conducted in Western countries. Whether this also applies in middle or low income countries like China where antibiotic resistance is becoming prevalent recently has not been evaluated. METHODS All the positive blood culture results from January 2010 to December 2013 in the 2 large Chinese cancer centers were reviewed. The patients were included into the study with the following criteria: febrile neutropenia, solid tumor or lymphoma, MASCC score >20, positive blood cultures within two days of the onset of fever, and detailed treatment history. RESULTS A total of 38 patients were included in this analysis. Two patients had polymicrobial bacteremia (Enterococcus faecalis and Flavimonas oryzihabitans). Other isolates included coagulase-negative staphylococcus, micrococcal species, viridans streptococci, Klebsiella pneumoniae, and Escherichia coli. The majority of the monomicrobial isolates from these 36 patients was Escherichia coli (28 patients, 74%). Notably, in contrast to the high sensitivity to fluoroquinolone from blood culture of the low risk patients in previous reports in Westen countries, a very high drug resistance was observed: 13 out of 28 Escherichia coli isolates (46%) or 14 out of all 38 positive cultures (37%). CONCLUSION The results warrant further validations in prospective clinical trials in countries where antibiotic resistance is prevalent to ensure appropriate antibiotic administration.
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Affiliation(s)
- Sheng Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China. .,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, 200032, Shanghai, China.
| | - Qing Wang
- Department of Clinical Laboratory, The Affiliated Hospital of Qingdao University Medical College, Shinan, Qingdao, Shandong, China.
| | - Yun Ling
- Department of Clinical Laboratory, Shanghai Cancer Center, Fudan University, Shanghai, China.
| | - Xichun Hu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China. .,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, 200032, Shanghai, China.
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Georgala A, Klastersky JA. Prophylaxis of febrile neutropenia in adults receiving chemotherapy needs to be adapted to the risk. Expert Rev Hematol 2014; 8:115-21. [PMID: 25431921 DOI: 10.1586/17474086.2015.983470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A major advance in the management of febrile neutropenia (FN) has been the stratification of the population of adult patients with FN for the risk of complications and death. Using validated reliable predictive instruments, such as the Multinational Association for Supportive Care in Cancer score, it is possible to identify a population of 'low-risk' patients, who can benefit from simplified and less expensive therapeutic approaches (e.g., orally administered antimicrobial therapy and early home return). Prevention of FN by the use of granulopoietic colony-stimulating factor (G-CSF) has been successfully applied to patients at 'high risk' of developing FN. In addition to the aggressiveness of chemotherapy, which usually defines the 'high-risk' status, the role of a series of factors that increase both the risk of FN and the complications rate has been recognized and should probably be taken into consideration when selecting patients for G-CSF prophylaxis. The cost of the G-CSF is the major limiting factor for their broad use; further efforts should be made to match the cost issue with the need of protecting from the development of FN most patients treated with chemotherapy for cancer.
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Affiliation(s)
- Aspasia Georgala
- Institut Jules Bordet - Université Libre de Bruxelles, Medicine, Rue Héger - Bordet 1, Brussels, 1000, Belgium
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Fontanella C, Bolzonello S, Lederer B, Aprile G. Management of breast cancer patients with chemotherapy-induced neutropenia or febrile neutropenia. ACTA ACUST UNITED AC 2014; 9:239-45. [PMID: 25404882 DOI: 10.1159/000366466] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chemotherapy-induced neutropenia (CIN) is a common toxicity caused by the administration of anticancer drugs. This side effect is associated with life-threatening infections and may alter the chemotherapy schedule, thus impacting on early and long-term outcomes. Elderly breast cancer patients with impaired health status or advanced disease as well as patients undergoing dose-dense anthracycline/taxane- or docetaxel-based regimens have the highest risk of CIN. A careful assessment of the baseline risk for CIN allows the selection of patients who need primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) and/or antimicrobial agents. Neutropenic cancer patients may develop febrile neutropenia and CIN-related severe medical complications. Specific risk assessment scores, along with comprehensive clinical evaluation, are able to define a group of febrile patients with low risk for complications who can be safely treated as outpatients. Conversely, patients with higher risk of severe complications should be hospitalized and should receive intravenous antibiotic therapy with or without G-CSF.
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Affiliation(s)
- Caterina Fontanella
- Department of Oncology, University Hospital of Udine, Italy ; German Breast Group, Neu-Isenburg, Germany
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Günalp M, Koyunoğlu M, Gürler S, Koca A, Yeşilkaya I, Öner E, Akkaş M, Metin Aksu N, Demirkan A, Polat O, Elhan AH. Independent factors for prediction of poor outcomes in patients with febrile neutropenia. Med Sci Monit 2014; 20:1826-32. [PMID: 25282155 PMCID: PMC4199395 DOI: 10.12659/msm.892269] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. Material/Methods We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred. Results The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. Conclusions The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.
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Affiliation(s)
- Müge Günalp
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Merve Koyunoğlu
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Serdar Gürler
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Ayça Koca
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Ilker Yeşilkaya
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Emre Öner
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Meltem Akkaş
- Department of Emergency Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Nalan Metin Aksu
- Department of Emergency Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Arda Demirkan
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Onur Polat
- Department of Emergency Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Atilla Halil Elhan
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
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Affiliation(s)
- Amy Ford
- Clatterbridge Cancer Centre, Bebington, UK
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Klastersky J, Georgala A. Strategies for the empirical management of infection in cancer patients with emphasis on the emergence of resistant gram-negative bacteria. Crit Rev Oncol Hematol 2014; 92:268-78. [PMID: 25151213 DOI: 10.1016/j.critrevonc.2014.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/20/2014] [Accepted: 06/23/2014] [Indexed: 01/23/2023] Open
Abstract
Combinations of antibiotics (namely penicillins and aminoglycosides) have been advocated in the 1970s for the empirical therapy of FN in cancer patients in order to take advantage of the possible synergism between these agents and to extend the potential antimicrobial spectrum of empirical therapy. Later, with the development of potent broad spectrum antibiotics, the need for combinations became less obvious as monotherapy with these new agents appeared as effective and less toxic than previously used combinations. However, today we are facing a major challenge through the emergence of multi-resistant microrganisms. With such bacteria, we might be coming back to the pre-antibiotic era when no active agents were available. This situation is due, in part, by the excessive use of antibiotics, namely as a prophylaxis for infection, and is complicated by the fact that very few new effective antibiotics are being developed by the pharmaceutical industry. Under these circumstances, it is likely that we will have to resort to "old timers" such as the polymyxins. It is also possible that combination therapy will come back in favor to take advantage of the synergism and extend the spectrum of coverage, just as it has been the case for the management of resistant tuberculosis. At the same time, the development of multidisciplinary antimicrobial stewardship is mandatory for efficient infection control and minimizing emergence of antimicrobial resistance.
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Affiliation(s)
- Jean Klastersky
- Department of Medicine, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Bruxelles, Belgium.
| | - Aspasia Georgala
- Department of Infectious Diseases, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Bruxelles, Belgium
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Wierema J, Konecny P, Links M. Implementation of risk stratified antibiotic therapy for neutropenic fever: what are the risks? Intern Med J 2014; 43:1116-24. [PMID: 23869563 DOI: 10.1111/imj.12251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 07/15/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND A new national guideline for the management of febrile patients with severe neutropenia uses a risk stratification score to tailor treatment. AIMS To evaluate the implementation of this guideline in a metropolitan teaching hospital. METHODS A protocol was developed for implementation of the national guidelines for patients with neutropenic fever or at risk because of recent chemotherapy. Medical records of all patients presenting with fever to the haematology and oncology service for 3 months in 2011 were audited. Patients with a neutrophil count between 0.5 and 1.0 × 10(9) /L were classified as borderline neutropenia. RESULTS Eighty-one episodes of fever were treated on the protocol. Forty-three per cent of patients were neutropenic. Uptake of the policy was low (35%) despite concerted efforts. The sensitivity and specificity of the Multinational Association for Supportive Care in Cancer score was 86% and 24% respectively. The readmission rate with fever was 19.2%. Median time to antibiotics was 60 min. Outcomes were similar for the neutropenic fever and borderline groups. Increasing treatment complexity was the major barrier to implementation. CONCLUSIONS The majority of presentations with cancer and fever following chemotherapy do not have neutropenia but have similar outcomes when treated on the same pathway. The utility of the Multinational Association for Supportive Care in Cancer score was limited by uptake and specificity. Reducing time to antibiotics administration and readmission rates were identified as priorities. Implementation was labour-intensive and faced significant barriers. Prioritisation of evidence for translation requires attention to local priorities and implementation complexity. These results argue for a single sepsis guideline with treatment of cancer as a high-risk group.
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Affiliation(s)
- J Wierema
- Faculty of Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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Abstract
OBJECTIVES The objectives of this study are to identify the characteristics of febrile gynecologic oncology patients and to evaluate the utility of common diagnostic procedures used to assess the etiologies of their fevers. METHODS/MATERIALS Retrospective data were collected for 200 consecutive patients admitted to the gynecologic oncology service at 1 institution between January 2008 and December 2012 for a diagnosis of fever. Data were collected using contingency tables, and the χ test was used as appropriate. RESULTS Of the patients admitted for evaluation of fever, 142 (71%) of 200 had a documented fever during hospitalization. The most common etiologies of fever in this population were urinary tract infections (28%) and bloodstream infections (27%), whereas 24% of those admitted for fever did not have a source identified. Abdominal/pelvic computed tomography (CT) scans established the etiology of fever in 53 (60%) of the 89 patients tested, whereas chest x-ray and chest CT were diagnostic for 6% and 21%, respectively. Blood and urine cultures were diagnostic in 29% and 32% of cases, respectively. Patients admitted within 30 days of surgery had a higher percentage of wound infections (38% vs 10%, P < 0.001) as compared with those admitted for more than 30 days after surgery. CONCLUSIONS The initial evaluation of the febrile gynecologic oncology patient without obvious source by history and examination should include urinalysis with reflex culture and blood cultures. Abdominopelvic and chest CT may be useful when fever persists and initial assessment is unrevealing. Chest x-ray is commonly done but infrequently diagnostic. Wound exploration may be important in patients with fevers for more than 30 days after surgery.
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Clinical practice in secondary prophylaxis and management of febrile neutropenia in Poland: results of the febrile neutropenia awareness project. Contemp Oncol (Pozn) 2014; 18:425-8. [PMID: 25784842 PMCID: PMC4355660 DOI: 10.5114/wo.2014.47905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/12/2014] [Accepted: 11/20/2014] [Indexed: 11/17/2022] Open
Abstract
Aim of the study This paper presents the second part of the GoPractice project involving oncologists from seven Polish provinces. The aim of this part of the project was to assess the knowledge of oncologists on indications for granulocyte colony-stimulating factor (G-CSF) secondary prophylaxis (SP) of febrile neutropenia (FN) and FN management based on current therapeutic guidelines (Polish Society of Clinical Oncology [PTOK] and European Organisation for Research and Treatment of Cancer [EORTC]). Material and methods The project involved 169 oncologists from 7 regions working in large specialist oncological centers, university hospitals, regional and city hospitals, specialist outpatient clinics and oncological wards in small, local hospitals. The participants completed a questionnaire based on 7 prepared clinical cases of patients with different tumor types and patient characteristics, receiving chemotherapy (CT) with different levels of FN risk. Participants answered questions related to FN risk assessment and G-CSF use as secondary prophylaxis (SP) and for the management of FN. After completing the questionnaire, the participants proceeded to an educational module in which they were provided with an analysis of correct diagnostic and therapeutic procedures according to the PTOK and EORTC guidelines. Results and Conclusions Indications for G-CSF SP were generally well recognized: in nearly 90% of responses, oncologists assessed correctly indications/lack of indications for secondary prophylaxis, in accordance with guideline recommendations and Experts’ opinion. However, the use of daily G-CSFs was often recommended by the study participants for the management of FN. This clinical practice is contradictory to PTOK and EORTC recommendations and may unnecessarily increase treatment costs. Changing this clinical approach may be achieved through regular training to improve guideline adherence.
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Lathia N, Isogai PK, Angelis CD, Smith TJ, Cheung M, Mittmann N, Hoch JS, Walker S. Cost-Effectiveness of Filgrastim and Pegfilgrastim as Primary Prophylaxis Against Febrile Neutropenia in Lymphoma Patients. ACTA ACUST UNITED AC 2013; 105:1078-85. [DOI: 10.1093/jnci/djt182] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Inpatient versus outpatient management of neutropenic fever in gynecologic oncology patients: is risk stratification useful? Gynecol Oncol 2013; 130:411-5. [PMID: 23791827 DOI: 10.1016/j.ygyno.2013.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aimed to evaluate the utility of risk stratification of gynecologic oncology patients with neutropenic fever (NF). METHODS A retrospective chart review of gynecologic cancer patients admitted with NF from 2007 to 2011 was performed, wherein demographic, oncologic, and NF characteristics (hospitalization length, complications, and death) were collected. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score was calculated; low risk was considered ≥ 21. SAS 9.2 was used for statistical analyses. RESULTS Eighty-three patients met the study criteria. Most (92%) were Caucasian and had advanced stage disease (71%). Primary tumors were 58% ovary, 35% endometrium, and 6% cervix. All patients were receiving chemotherapy on admission (72% for primary, 28% for recurrent disease). Forty-eight percent had a positive culture, and most (58%) positive cultures were urine. Seventy-six percent of patients were considered low risk. High-risk patients were more likely to have a severe complication (10% versus 50%, p=0.0003), multiple severe complications (3% versus 20%, p=0.0278), ICU admission (2% versus 40%, p<0.0001), overall mortality (2% versus 15%, p=0.0417), and death due to neutropenic fever (0% versus 15%, p=0.0124). MASCC had a positive predictive value of 50% and negative predictive value of 90%. The median MASCC score for all patients was 22 (range, 11-26), but the median MASCC score for those with death or a severe complication was 17 (range, 11-24). CONCLUSION Based on this pilot data, MASCC score appears promising in determining suitability for outpatient management of NF in gynecologic oncology patients. Prospective study is ongoing to confirm safety and determine impact on cost.
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Hocking C, Taylor A, Hayward A. Early discharge and ambulatory care of low-risk patients with neutropenic fever in Australia. Intern Med J 2013; 43:591-5. [DOI: 10.1111/imj.12117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/10/2012] [Indexed: 12/01/2022]
Affiliation(s)
- C. Hocking
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - A. Taylor
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - A. Hayward
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
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Abstract
The purpose of this study is to determine whether, in low-risk febrile neutropenic paediatric populations, oral antibiotics are as effective as intravenous antibiotics in obtaining resolution of the febrile neutropenic episode. A comprehensive literature search of MEDLINE, EMBASE and CENTRAL identified prospective, randomised controlled trials comparing oral antibiotics with intravenous antibiotics in the treatment of febrile neutropenic episodes in low-risk paediatric oncology patients. Outcomes assessed were mortality, rate of treatment failure, length of the febrile neutropenic episode and adverse events. The random effects model was used to calculate risk ratios (RRs) for dichotomous data and mean difference with standard deviation for continuous data. Seven trials were included in the overall analysis, which included 934 episodes of febrile neutropenia in 676 patients aged between 9 months and 20 years. The overall treatment failure rates were not significantly different between oral and intravenous antibiotics (RR: 1.02, 95% confidence interval 0.78-1.32, P= 0.91). In carefully selected low-risk febrile neutropenic children, empiric treatment with oral antibiotics is a safe and effective alternative to intravenous antibiotics as they lower the cost of treatment as well as psychosocial burden on these children and their families.
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Affiliation(s)
- Aditi Vedi
- Sydney Children's Hospital, University of New South Wales, Sydney, New South Wales, Australia.
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Chindaprasirt J, Wanitpongpun C, Limpawattana P, Thepsuthammarat K, Sripakdee W, Wirasorn K, Sookprasert A. Mortality, Length of Stay, and Cost Associated with Hospitalized Adult Cancer Patients with Febrile Neutropenia. Asian Pac J Cancer Prev 2013; 14:1115-9. [DOI: 10.7314/apjcp.2013.14.2.1115] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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The Multinational Association for Supportive Care in Cancer (MASCC) risk index score: 10 years of use for identifying low-risk febrile neutropenic cancer patients. Support Care Cancer 2013; 21:1487-95. [PMID: 23443617 DOI: 10.1007/s00520-013-1758-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 02/11/2013] [Indexed: 01/20/2023]
Abstract
The Multinational Association for Supportive Care in Cancer risk index score developed, through a multinational collaboration, was published in 2000 with the aim to identify patients with chemotherapy-induced febrile neutropenia at low risk of serious medical complication development. It has been endorsed as a reliable tool since 2002 by Infectious Diseases Society of America. Ten years after, we thought worth to review its use, its characteristics in the external validations that occurred after the initial publication and also to review how the recognition of a group of patients at low risk has changed the management of febrile neutropenia. We also raise the issue of identification of high-risk patients that remains a challenge today.
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Kern WV, Marchetti O, Drgona L, Akan H, Aoun M, Akova M, de Bock R, Paesmans M, Viscoli C, Calandra T. Oral antibiotics for fever in low-risk neutropenic patients with cancer: a double-blind, randomized, multicenter trial comparing single daily moxifloxacin with twice daily ciprofloxacin plus amoxicillin/clavulanic acid combination therapy--EORTC infectious diseases group trial XV. J Clin Oncol 2013; 31:1149-56. [PMID: 23358983 DOI: 10.1200/jco.2012.45.8109] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE This double-blind, multicenter trial compared the efficacy and safety of a single daily oral dose of moxifloxacin with oral combination therapy in low-risk febrile neutropenic patients with cancer. PATIENTS AND METHODS Inclusion criteria were cancer, febrile neutropenia, low risk of complications as predicted by a Multinational Association for Supportive Care in Cancer (MASCC) score > 20, ability to swallow, and ≤ one single intravenous dose of empiric antibiotic therapy before study drug treatment initiation. Early discharge was encouraged when a set of predefined criteria was met. Patients received either moxifloxacin (400 mg once daily) monotherapy or oral ciprofloxacin (750 mg twice daily) plus amoxicillin/clavulanic acid (1,000 mg twice daily). The trial was designed to show equivalence of the two drug regimens in terms of therapy success, defined as defervescence and improvement in clinical status during study drug treatment (< 10% difference). RESULTS Among the 333 patients evaluated in an intention-to-treat analysis, therapy success was observed in 80% of the patients administered moxifloxacin and in 82% of the patients administered combination therapy (95% CI for the difference, -10% to 8%, consistent with equivalence). Minor differences in tolerability, safety, and reasons for failure were observed. More than 50% of the patients in the two arms were discharged on protocol therapy, with 5% readmissions among those in either arm. Survival was similar (99%) in both arms. CONCLUSION Monotherapy with once daily oral moxifloxacin is efficacious and safe in low-risk febrile neutropenic patients identified with the help of the MASCC scoring system, discharged early, and observed as outpatients.
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Flowers CR, Seidenfeld J, Bow EJ, Karten C, Gleason C, Hawley DK, Kuderer NM, Langston AA, Marr KA, Rolston KVI, Ramsey SD. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013; 31:794-810. [PMID: 23319691 DOI: 10.1200/jco.2012.45.8661] [Citation(s) in RCA: 287] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia. METHODS A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus. RESULTS Forty-seven articles from 43 studies met selection criteria. RECOMMENDATIONS Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.
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A proposal for a simplified MASCC score. Support Care Cancer 2012; 21:915-6. [PMID: 23247772 DOI: 10.1007/s00520-012-1676-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW Most patients with chemotherapy-induced febrile neutropenia recover rapidly without serious complications. However, it still remains a life-threatening treatment-related toxicity, and is associated with dose reductions and delays of chemotherapeutic agents that may compromise treatment outcomes. Recent developments of risk stratification enabled early discharge with oral antibiotics for low-risk patients. However, even in low-risk patients, medical complications including bacteremia could happen. The authors reviewed recent literature to provide an update on research regarding predictive factors for poor prognosis in patients with febrile neutropenia. RECENT FINDINGS Various prognostic factors have been suggested with controversies. Hematological parameters, prophylactic measurements and patient-specific risk factors showed inconsistent results. MASCC risk-index score, which was originally developed to identify low-risk patients, in turn showed that the lower the MASCC score, the poorer the prognosis of febrile neutropenia, with very low levels (<15), the rate of complications was high. Patients with severe sepsis and septic shock commonly had procalcitonin concentration above 2.0 ng/ml, and this level should be considered at high risk of poor prognosis. SUMMARY Lower MASCC score and higher procalcitonin concentration can predict poor outcomes in febrile neutropenia. More research is required with regard to the other factors showing controversies.
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Schelenz S, Giles D, Abdallah S. Epidemiology, management and economic impact of febrile neutropenia in oncology patients receiving routine care at a regional UK cancer centre. Ann Oncol 2012; 23:1889-93. [DOI: 10.1093/annonc/mdr520] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lathia N, Isogai PK, Walker SE, De Angelis C, Cheung MC, Hoch JS, Mittmann N. Eliciting patients' preferences for outpatient treatment of febrile neutropenia: a discrete choice experiment. Support Care Cancer 2012; 21:245-51. [PMID: 22684150 DOI: 10.1007/s00520-012-1517-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/28/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies have demonstrated that patients at low risk for febrile neutropenia (FN) complications can be treated safely and effectively at home. Information on patient preferences for outpatient treatment of this condition will help to optimize health care delivery to these patients. The purpose of this study was to elicit non-Hodgkin lymphoma patients' preferences on attributes related to outpatient treatment of FN. METHODS We used a self-administered discrete choice experiment questionnaire based on the attributes of out-of-pocket costs, unpaid caregiver time required daily, and probability of return to the hospital. Ten paired scenarios in which levels of the attributes were varied were presented to study patients. For each pair, patients indicated the scenario they preferred. Adjusted odds ratios (ORs) of accepting a scenario that described outpatient care for FN were estimated. RESULTS Eighty-eight patients completed the questionnaire. Adjusted ORs [95 % confidence intervals] of accepting outpatient care for FN were 0.84 [0.75, 0.95] for each $10 increase in out-of-pocket cost; 0.82 [0.68, 0.99] for each 1 h increase in daily unpaid caregiver time; and 0.53 [0.50, 0.57] for each 5 % increase in probability of return to the hospital. CONCLUSIONS Probability of return to the hospital was the most important attribute to patients when considering home-based care for FN. Patients considered out-of-pocket costs and unpaid caregiver time to be less important than probability of return to the hospital. This study identifies factors that could be incorporated into outpatient delivery systems for FN care to ensure adequate patient uptake and satisfaction with such programs.
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Affiliation(s)
- Nina Lathia
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada.
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Abstract
BACKGROUND Neutropenic fever in patients receiving chemotherapy is a medical emergency and should be treated promptly within 1 h with antibiotics as specified within the 2009 NCAG report on chemotherapy services. AIM To determine door-to-assessment, door-to-treatment and door-to-investigation intervals for patients with febrile neutropenia who presented to the inpatient Oncology Ward, the outpatient Oncology Day Unit and the Emergency Department in Addenbrooke's Hospital, Cambridge. DESIGN Retrospective observational audit. METHODS Thirty-two patients on treatment for solid cancers who were admitted with febrile neutropenia between January and December 2010 were identified, and paper and electronic medical records were analysed to determine door to: assessment, treatment and investigation intervals. RESULTS AND CONCLUSIONS Patients in this series were assessed quicker and received the first dose of antibiotics faster when they presented to an oncology ward rather than the emergency department. However, imaging was performed faster and blood results issued quicker if performed in the emergency department due to a better infrastructure that has been tailored to comply with national targets. Nonetheless, compliance with optimum standards of care was poor, with only 9% of sampled patients getting antibiotics within 1 h of presenting to hospital, and 53% within 1 h of being assessed by a clinician.
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Affiliation(s)
- S J Sammut
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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How to Manage Neutropenia in Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 12:5-11. [DOI: 10.1016/j.clml.2011.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 10/14/2011] [Accepted: 11/09/2011] [Indexed: 11/20/2022]
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Lingaratnam S, Worth LJ, Slavin MA, Bennett CA, Kirsa SW, Seymour JF, Dalton A, Koczwara B, Prince HM, O'Reilly M, Mileshkin L, Szer J, Thursky KA. A cost analysis of febrile neutropenia management in Australia: ambulatory v. in-hospital treatment. AUST HEALTH REV 2012; 35:491-500. [PMID: 22126955 DOI: 10.1071/ah10951] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 01/13/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Adult febrile neutropenic oncology patients, at low risk of developing medical complications, may be effectively and safely managed in an ambulatory setting, provided they are appropriately selected and adequate supportive facilities and clinical services are available to monitor these patients and respond to any clinical deterioration. METHODS A cost analysis was modelled using decision tree analysis, published cost and effectiveness parameters for ambulatory care strategies and data from the State of Victoria's hospital morbidity dataset. Two-way sensitivity analyses and Monte Carlo simulation were performed to evaluate the uncertainty of costs and outcomes associated with ambulatory care. RESULTS The modelled cost analysis showed that cost savings for two ambulatory care strategies were ~30% compared to standard hospital care. The weighted average cost saving per episode of 'low-risk' febrile neutropenia using Strategy 1 (outpatient follow-up only) was 35% (range: 7-55%) and that for Strategy 2 (early discharge and outpatient follow-up) was 30% (range: 7-39%). Strategy 2 was more cost-effective than Strategy 1 and was deemed the more clinically favoured approach. CONCLUSION This study outlines a cost structure for a safe and comprehensive ambulatory care program comprised of an early discharge pathway with outpatient follow-up, and promotes this as a cost effective approach to managing 'low-risk' febrile neutropenic patients.
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Affiliation(s)
- Senthil Lingaratnam
- Pharmacy Department, Peter MacCallum Cancer Centre, East Melbourne, VIC 3002, Australia.
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