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Forcano-Queralt E, Lemes-Quintana C, Orozco-Beltrán D. Ambulatory management of low-risk febrile neutropenia in adult oncological patients. Systematic review. Support Care Cancer 2023; 31:665. [PMID: 37921996 PMCID: PMC10624743 DOI: 10.1007/s00520-023-08065-y] [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] [Received: 04/25/2022] [Accepted: 09/22/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE Recent clinical practice guidelines have recommended ambulatory management of febrile neutropenia in patients with low risk of complications. Although some centers have begun developing management protocols for these patients, there appears to be a certain reluctance to implement them in clinical practice. Our aim is to evaluate the strengths and weaknesses of this strategy according to available evidence and to propose new lines of research. METHODS Systematic review using a triple aim approach (efficacy, cost-effectiveness, and quality of life), drawing from literature in MEDLINE (PubMed), Embase, and Cochrane Library databases. The review includes studies that assess ambulatory management for efficacy, cost-efficiency, and quality of life. RESULTS The search yielded 27 articles that met our inclusion criteria. CONCLUSION In conclusion, based on current evidence, ambulatory management of febrile neutropenia is safe, more cost-effective than inpatient care, and capable of improving quality of life in oncological patients with this complication. Ambulatory care seems to be an effective alternative to hospitalization in these patients.
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Affiliation(s)
- Ester Forcano-Queralt
- Gran Canaria Island Maternal-Infant University Hospital Complex, 35016, Las Palmas de Gran Canaria, Spain
| | - Cristina Lemes-Quintana
- Gran Canaria Island Maternal-Infant University Hospital Complex, 35016, Las Palmas de Gran Canaria, Spain
| | - Domingo Orozco-Beltrán
- Clinical Medicine Department, School of Medicine, University Miguel Hernández de Elche, 03550, San Juan de Alicante, Spain.
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Hwang S, Kwon KT, Kim Y, Bae S, Chang HH, Kim SW, Yoo SS, Nam SY, Baek JH. Usefulness analysis of the 2018 ASCO/IDSA guideline for outpatient management of fever and neutropenia in adults treated for malignancy. Sci Rep 2021; 11:9048. [PMID: 34526516 PMCID: PMC8443648 DOI: 10.1038/s41598-021-88207-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/22/2021] [Indexed: 01/04/2023] Open
Abstract
Although the clinical practice guideline for outpatient management of febrile neutropenia (FN) in adults treated for malignancy was updated by the ASCO/IDSA in 2018, most patients with FN in our hospital have been hospitalized. We performed this study to analyze the usefulness of the guideline. The medical records of patients hospitalized for FN in Kyungpook National University Chilgok Hospital from May 2016 to April 2018 were retrospectively reviewed. The feasibility of candidates for outpatient management according to the guideline was evaluated based on the outcomes. A total of 114 patients were enrolled and categorized into two groups, low-risk (38.6%) and high-risk (61.4%). The proportion of feasible candidates for outpatient management was 70.2% and was higher in the low-risk than in the high-risk group (90.0% vs. 57.1%; P < 0.001). The low-risk group had no mortality, no resistance to oral amoxicillin/clavulanate or ciprofloxacin, a higher rate of successful empirical antibiotics, and lower rates of glycopeptide or carbapenem administration. A significant number of hospitalized cancer patients treated for FN after chemotherapy were found to be feasible candidates for outpatient management. The guideline can be a useful tool to reduce labor of healthcare workers and hospitalization costs.
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Affiliation(s)
- Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea.
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea
| | - Seung Soo Yoo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Su Youn Nam
- Gastroenterology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jin Ho Baek
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Mogi A, Sasaki H, Nakashima Y, Chinen S, Ishizu M, Tanaka T, Takata T, Takamatsu Y. Efficacy of oral levofloxacin monotherapy against low-risk FN in patients with malignant lymphoma who received chemotherapy using the CHOP regimen. J Clin Exp Hematop 2020; 60:73-77. [PMID: 32779614 PMCID: PMC7596912 DOI: 10.3960/jslrt.20008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The safety and feasibility of oral fluoroquinolone monotherapy in patients with low-risk febrile neutropenia (FN) were demonstrated in recent studies. Levofloxacin (LVFX) is a commonly prescribed antibiotic; however, evidence for its efficacy against FN is limited. Therefore, in this study, we retrospectively investigated the efficacy of LVFX against low-risk FN in patients with malignant lymphoma at our institution. Treatment success was defined as recovery from fever and neutropenia without alteration of the initial regimen. We recruited 29 patients between January 2013 and December 2018. The median age of the cohort was 64 (range: 21–87) years; 13 (44.8%) were aged over 65 years. In total, 22 patients had diffuse large B-cell lymphoma (DLBCL). Therapy was successful in 24 (82.8%) patients, whereas 5 had treatment failure requiring a change from LVFX to intravenous broad-spectrum antibacterial agents. No deaths related to FN were observed. Two patients required FN-related chemotherapy dose reduction in subsequent cycles. Although this cohort comprised many elderly patients, our study confirmed the efficacy of LVFX in patients with low-risk FN. This may improve the treatment of low-risk FN and malignant lymphoma.
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Affiliation(s)
- Ai Mogi
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Hidenori Sasaki
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Yuta Nakashima
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Shotaro Chinen
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Masanao Ishizu
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Toshihiro Tanaka
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Tohru Takata
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
| | - Yasushi Takamatsu
- Division of Medical Oncology, Hematology and Infection Disease, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
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Joncour A, Puyade M, Michaud A, Tourani JM, Cazenave-Roblot F, Rammaert B. Is current initial empirical antibiotherapy appropriate to treat bloodstream infections in short-duration chemo-induced febrile neutropenia? Support Care Cancer 2019; 28:3103-3111. [DOI: 10.1007/s00520-019-05113-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
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Rivas‐Ruiz R, Villasis‐Keever M, Miranda‐Novales G, Castelán‐Martínez OD, Rivas‐Contreras S. Outpatient treatment for people with cancer who develop a low-risk febrile neutropaenic event. Cochrane Database Syst Rev 2019; 3:CD009031. [PMID: 30887505 PMCID: PMC6423292 DOI: 10.1002/14651858.cd009031.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with febrile neutropaenia are usually treated in a hospital setting. Recently, treatment with oral antibiotics has been proven to be as effective as intravenous therapy. However, the efficacy and safety of outpatient treatment have not been fully evaluated. OBJECTIVES To compare the efficacy (treatment failure and mortality) and safety (adverse events of antimicrobials) of outpatient treatment compared with inpatient treatment in people with cancer who have low-risk febrile neutropaenia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library, MEDLINE via Ovid (from 1948 to November week 4, 2018), Embase via Ovid (from 1980 to 2018, week 48) and trial registries (National Cancer Institute, MetaRegister of Controlled Trials, Medical Research Council Clinical Trial Directory). We handsearched all references of included studies and major reviews. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing outpatient with inpatient treatment for people with cancer who develop febrile neutropaenia. The outpatient group included those who started treatment as an inpatient and completed the antibiotic course at home (sequential) as well as those who started treatment at home. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, methodological quality, and extracted data. Primary outcome measures were: treatment failure and mortality; secondary outcome measures considered were: duration of fever, adverse drug reactions to antimicrobial treatment, duration of neutropaenia, duration of hospitalisation, duration of antimicrobial treatment, and quality of life (QoL). We estimated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data; we calculated weighted mean differences for continuous data. Random-effects meta-analyses and sensitivity analyses were conducted. MAIN RESULTS We included ten RCTs, six in adults (628 participants) and four in children (366 participants). We found no clear evidence of a difference in treatment failure between the outpatient and inpatient groups, either in adults (RR 1.23, 95% CI 0.82 to 1.85, I2 0%; six studies; moderate-certainty evidence) or children (RR 1.04, 95% CI 0.55 to 1.99, I2 0%; four studies; moderate-certainty evidence). For mortality, we also found no clear evidence of a difference either in studies in adults (RR 1.04, 95% CI 0.29 to 3.71; six studies; 628 participants; moderate-certainty evidence) or in children (RR 0.63, 95% CI 0.15 to 2.70; three studies; 329 participants; moderate-certainty evidence).According to the type of intervention (early discharge or exclusively outpatient), meta-analysis of treatment failure in four RCTs in adults with early discharge (RR 1.48, 95% CI 0.74 to 2.95; P = 0.26, I2 0%; 364 participants; moderate-certainty evidence) was similar to the results of the exclusively outpatient meta-analysis (RR 1.15, 95% CI 0.62 to 2.13; P = 0.65, I2 19%; two studies; 264 participants; moderate-certainty evidence).Regarding the secondary outcome measures, we found no clear evidence of a difference between outpatient and inpatient groups in duration of fever (adults: mean difference (MD) 0.2, 95% CI -0.36 to 0.76, 1 study, 169 participants; low-certainty evidence) (children: MD -0.6, 95% CI -0.84 to 0.71, 3 studies, 305 participants; low-certainty evidence) and in duration of neutropaenia (adults: MD 0.1, 95% CI -0.59 to 0.79, 1 study, 169 participants; low-certainty evidence) (children: MD -0.65, 95% CI -0.1.86 to 0.55, 2 studies, 268 participants; moderate-certainty evidence). With regard to adverse drug reactions, although there was greater frequency in the outpatient group, we found no clear evidence of a difference when compared to the inpatient group, either in adult participants (RR 8.39, 95% CI 0.38 to 187.15; three studies; 375 participants; low-certainty evidence) or children (RR 1.90, 95% CI 0.61 to 5.98; two studies; 156 participants; low-certainty evidence).Four studies compared the hospitalisation time and found that the mean number of days of hospital stay was lower in the outpatient treated group by 1.64 days in adults (MD -1.64, 95% CI -2.22 to -1.06; 3 studies, 251 participants; low-certainty evidence) and by 3.9 days in children (MD -3.90, 95% CI -5.37 to -2.43; 1 study, 119 participants; low-certainty evidence). In the 3 RCTs of children in which days of antimicrobial treatment were analysed, we found no difference between outpatient and inpatient groups (MD -0.07, 95% CI -1.26 to 1.12; 305 participants; low-certainty evidence).We identified two studies that measured QoL: one in adults and one in children. QoL was slightly better in the outpatient group than in the inpatient group in both studies, but there was no consistency in the domains included. AUTHORS' CONCLUSIONS Outpatient treatment for low-risk febrile neutropaenia in people with cancer probably makes little or no difference to treatment failure and mortality compared with the standard hospital (inpatient) treatment and may reduce time that patients need to be treated in hospital.
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Affiliation(s)
- Rodolfo Rivas‐Ruiz
- Insitiuto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXICentro de adiestramiento en Investigación ClínicaHospital de Pediatria del CMN SXXIAvenida Cuauhtemoc #330Mexico CityMexico
| | - Miguel Villasis‐Keever
- Instituto Mexicano del Seguro SocialClinical Epidemiology Research UnitMexico CityDFMexicoCP 06470
| | | | - Osvaldo D Castelán‐Martínez
- Universidad Nacional Autónoma de MéxicoFacultad de Estudios Superiores ZaragozaBatalla 5 de mayo s/n esquina Fuerte de LoretoCol. Ejercito de Oriente, Iztapalapa, C.P. 09230Mexico CityMexico
| | - Silvia Rivas‐Contreras
- Instituto de Salud del Estado de MexicoCentro de Atención Primaria a la Salud TlalmanalcoAvenida Mirador No. 40TlamanalcoMexico56700
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Effectiveness and safety of the pre-prescription of garenoxacin in comparison to moxifloxacin for low-risk febrile neutropenia in breast cancer patients undergoing adjuvant and neoadjuvant chemotherapy. Support Care Cancer 2018; 27:2829-2836. [PMID: 30547304 DOI: 10.1007/s00520-018-4589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to compare the efficacy of the pre-prescription of garenoxacin mesylate hydrate (GRNX) with that of moxifloxacin hydrochloride (MFLX) in the management of breast cancer patients with low-risk febrile neutropenia. METHODS Data from female patients who had been instructed to take previously prescribed oral GRNX or MFLX for 3 days during adjuvant and neoadjuvant chemotherapy if their body temperature exceeded 38 °C were analyzed. This study compared the effectiveness between these fluoroquinolones using a propensity score matching analysis. RESULTS The 330 patients received 1192 administrations of chemotherapy between May 2007 and April 2014 and 136 (41.2%) patients had a total of 212 (17.8%) febrile episodes. The frequencies of febrile episodes were 19.5% (113/579) and 16.2% (99/613) in the GRNX and MFLX groups, respectively. After propensity score matching, 384 episodes were matched in each group. Febrile events occurred in 80 and 56 cases in the GRNX and MFLX groups, respectively. Treatment success was identified in 80.0% (64/80) of cases in the GRNX group and 64.3% (36/56) of cases in the MFLX group (P = 0.0494). Additionally, the therapeutic use of granulocyte-colony stimulating factor was 6.3% (5/80) of cases in the GRNX group and 17.9% (10/56) of cases in the MFLX group (P = 0.0498). There were few differences in the frequency of adverse effects between the two groups. CONCLUSIONS These results indicate that the pre-prescription of GRNX may be a more effective option for the management of low-risk febrile neutropenia during adjuvant and neoadjuvant chemotherapy for breast cancer.
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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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Mitchell ED, Czoski Murray C, Meads D, Minton J, Wright J, Twiddy M. Clinical and cost-effectiveness, safety and acceptability of community intra venous antibiotic service models: CIVAS systematic review. BMJ Open 2017; 7:e013560. [PMID: 28428184 PMCID: PMC5775457 DOI: 10.1136/bmjopen-2016-013560] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models. DESIGN A systematic review. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015. STUDY SELECTION All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion. RESULTS 128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT. CONCLUSIONS There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.
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Affiliation(s)
- E D Mitchell
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - C Czoski Murray
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Minton
- Department of Infection and Travel Medicine, Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Twiddy
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Minton J, Murray CC, Meads D, Hess S, Vargas-Palacios A, Mitchell E, Wright J, Hulme C, Raynor DK, Gregson A, Stanley P, McLintock K, Vincent R, Twiddy M. The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BackgroundOutpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.ObjectivesThe aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.MethodsThis mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.ResultsThe systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.LimitationsRecruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.ConclusionsThe quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.Future workFurther research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.FundingThe National Institute for Health Research Health Service and Delivery Research programme.
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Affiliation(s)
- Jane Minton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephane Hess
- Institute of Transport Studies, University of Leeds, Leeds, UK
| | | | | | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Philip Stanley
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kate McLintock
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Kimura K, Tanaka S, Iwamoto M, Fujioka H, Sato N, Terasawa R, Kawaguchi K, Matsuda J, Umezaki N, Uchiyama K. Outpatient management without initial assessment for febrile patients undergoing adjuvant chemotherapy for breast cancer. Mol Clin Oncol 2016; 5:385-390. [PMID: 27699031 DOI: 10.3892/mco.2016.992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/25/2016] [Indexed: 11/06/2022] Open
Abstract
The purpose of this study was to retrospectively analyze the feasibility of outpatient management without initial assessment for febrile patients undergoing adjuvant chemotherapy for breast cancer. A total of 131 consecutive patients with breast cancer treated with adjuvant or neoadjuvant chemotherapy from 2011 to 2013 at Osaka Medical College Hospital (Osaka, Japan) were retrospectively reviewed. In the case of developing a fever (body temperature, ≥38°C), the outpatients had been instructed to take previously prescribed oral antibiotics for 3 days without any initial assessment, and if no improvement had occurred by then, they were required to visit the hospital for examination and to undergo treatment based on the results of a risk assessment for complications. The primary aim of the present study was to assess the outcome of febrile episodes, while the secondary aim was to assess the incidence of febrile episodes, hospitalizations, and the type of chemotherapy. The 131 patients received 840 chemotherapy administrations. Fifty-five patients (42.0%) had a total of 75 febrile episodes after 840 chemotherapy administrations (8.9%). Treatment failure occurred in 12 of the 75 episodes (16.0%) in 11 of the 55 patients (20.0%). Only four episodes required hospitalization. Treatment success was achieved in 63 episodes (84.0%). In conclusion, the feasibility of outpatient management without initial assessment was evaluated in the present study for febrile patients undergoing adjuvant chemotherapy for breast cancer, and the outpatient strategy regimen may be safe and convenient for these patients.
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Affiliation(s)
- Kosei Kimura
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Satoru Tanaka
- Department of Breast Surgery, National Hospital Organization Osaka-Minami Medical Center, Kawachinagano, Osaka 586-8521, Japan
| | - Mitsuhiko Iwamoto
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Hiroya Fujioka
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Nayuko Sato
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Risa Terasawa
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Kanako Kawaguchi
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Junna Matsuda
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Nodoka Umezaki
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
| | - Kazuhisa Uchiyama
- Department of Breast and Endocrine Surgery, Osaka Medical College Hospital, Takatsuki, Osaka 569-8686, Japan
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Loizidou A, Aoun M, Klastersky J. Fever of unknown origin in cancer patients. Crit Rev Oncol Hematol 2016; 101:125-30. [PMID: 26995082 DOI: 10.1016/j.critrevonc.2016.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 01/14/2016] [Accepted: 02/24/2016] [Indexed: 12/11/2022] Open
Abstract
Fever of unknown origin (FUO) remains a challenging clinical problem, namely in patients with cancer. In cancer patients, FUO may be due to the cancer itself, as it is the case of hematological malignancies; digestive tumors (colon cancer, liver metastases) are significantly associated with FUO and infection can be demonstrated in some cases. Prevention with G-CSF and empirical antimicrobial therapy are essential approaches for the management of FUO in cancer patients. New diagnostic approaches, such as PET imaging, should be further evaluated in cancer patients with FUO.
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Affiliation(s)
- A Loizidou
- Medicine Department, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium
| | - M Aoun
- Medicine Department, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium
| | - J Klastersky
- Medicine Department, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium.
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Koinis F, Nintos G, Georgoulias V, Kotsakis A. Therapeutic strategies for chemotherapy-induced neutropenia in patients with solid tumors. Expert Opin Pharmacother 2015; 16:1505-19. [DOI: 10.1517/14656566.2015.1055248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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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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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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15
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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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Chilet-Rosell E, Ruiz-Cantero MT, Pardo MA. Gender analysis of moxifloxacin clinical trials. J Womens Health (Larchmt) 2013; 23:77-104. [PMID: 24180298 DOI: 10.1089/jwh.2012.4171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To determine the inclusion of women and the sex-stratification of results in moxifloxacin Clinical Trials (CTs), and to establish whether these CTs considered issues that specifically affect women, such as pregnancy and use of hormonal therapies. Previous publications about women's inclusion in CTs have not specifically studied therapeutic drugs. Although this type of drug is taken by men and women at a similar rate, adverse effects occur more frequently in the latter. METHODS We reviewed 158 published moxifloxacin trials on humans, retrieved from MedLine and the Cochrane Library (1998-2010), to determine whether they complied with the gender recommendations published by U.S. Food and Drug Administration Guideline. RESULTS Of a total of 80,417 subjects included in the moxifloxacin CTs, only 33.7% were women in phase I, in contrast to phase II, where women accounted for 45%, phase III, where they represented 38.3% and phase IV, where 51.3% were women. About 40.9% (n=52) of trials were stratified by sex and 15.3% (n=13) and 9% (n=7) provided data by sex on efficacy and adverse effects, respectively. We found little information about the influence of issues that specifically affect women. Only 3 of the 59 journals that published the moxifloxacin CTs stated that authors should stratify their results by sex. CONCLUSIONS Women are under-represented in the published moxifloxacin trials, and this trend is more marked in phase I, as they comprise a higher proportion in the other phases. Data by sex on efficacy and adverse effects are scarce in moxifloxacin trials. These facts, together with the lack of data on women-specific issues, suggest that the therapeutic drug moxifloxacin is only a partially evidence-based medicine.
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Vidal L, Ben dor I, Paul M, Eliakim‐Raz N, Pokroy E, Soares‐Weiser K, Leibovici L. Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. Cochrane Database Syst Rev 2013; 2013:CD003992. [PMID: 24105485 PMCID: PMC6457615 DOI: 10.1002/14651858.cd003992.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fever occurring in a neutropenic patient remains a common life-threatening complication of cancer chemotherapy. The common practice is to admit the patient to hospital and treat him or her empirically with intravenous broad-spectrum antibiotics. Oral therapy could be an alternative approach for selected patients. OBJECTIVES To compare the efficacy of oral antibiotics versus intravenous (IV) antibiotic therapy in febrile neutropenic cancer patients. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1) in The Cochrane Library, MEDLINE (1966 to January week 4, 2013), EMBASE (1980 to 2013 week 4) and LILACS (1982 to 2007). We searched several databases for ongoing trials. We checked the conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) (1995 to 2007), and all references of included studies and major reviews were scanned. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing oral antibiotic(s) to intravenous antibiotic(s) for the treatment of neutropenic cancer patients with fever. The comparison between the two could be started initially (initial oral) or following an initial course of intravenous antibiotic treatment (sequential). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and methodological quality and extracted data. Data concerning mortality, treatment failures and adverse events were extracted from the included studies assuming an 'intention-to-treat' basis for the outcome measures whenever possible. Risk ratios (RR) with 95% confidence intervals (CI) were estimated for dichotomous data. Risk of bias assessment was also made in line with methodology of The Cochrane Collaboration. MAIN RESULTS Twenty-two trials (3142 episodes in 2372 patients) were included in the analyses. The mortality rate was similar when comparing oral to intravenous antibiotic treatment (RR 0.95, 95% CI 0.54 to 1.68, 9 trials, 1392 patients, median mortality 0, range 0% to 8.8%). Treatment failure rates were also similar (RR 0.96, 95% CI 0.86 to 1.06, all trials). No significant heterogeneity was shown for all comparisons but adverse events. The effect was stable in a wide range of patients. Quinolones alone or combined with another antibiotic were used with comparable results. Adverse reactions, mostly gastrointestinal, were more common with oral antibiotics. AUTHORS' CONCLUSIONS Based on the present data, oral treatment is an acceptable alternative to intravenous antibiotic treatment in febrile neutropenic cancer patients (excluding patients with acute leukaemia) who are haemodynamically stable, without organ failure, and do not have pneumonia, infection of a central line or a severe soft-tissue infection. The wide CI for mortality allows the present use of oral treatment in groups of patients with an expected low risk for mortality, and further research should be aimed at clarifying the definition of low risk patients.
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Affiliation(s)
- Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Itsik Ben dor
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Noa Eliakim‐Raz
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Ellisheva Pokroy
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine A39 Jabotinski StreetPetah TikvaIsrael49100
| | - Karla Soares‐Weiser
- CochraneCochrane Editorial UnitSt Albans House, 57 ‐ 59 HaymarketLondonUKSW1Y 4QX
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Castagnola E, Mikulska M, Barabino P, Lorenzi I, Haupt R, Viscoli C. Current research in empirical therapy for febrile neutropenia in cancer patients: what should be necessary and what is going on. Expert Opin Emerg Drugs 2013; 18:263-78. [DOI: 10.1517/14728214.2013.809419] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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20
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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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21
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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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22
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Health-related quality of life anticipated with different management strategies for febrile neutropenia in adult cancer patients. Support Care Cancer 2012; 20:2755-64. [DOI: 10.1007/s00520-012-1397-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 01/25/2012] [Indexed: 11/26/2022]
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Kamioner D, Aapro M, Cheze S, Deblock M. Prise en charge initiale de la neutropénie fébrile. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Freifeld AG, Sepkowitz KA. No Place Like Home? Outpatient Management of Patients With Febrile Neutropenia and Low Risk. J Clin Oncol 2011; 29:3952-4. [DOI: 10.1200/jco.2011.37.5758] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Cooper MR, Durand CR, Beaulac MT, Steinberg M. Single-Agent, Broad-Spectrum Fluoroquinolones for the Outpatient Treatment of Low-Risk Febrile Neutropenia. Ann Pharmacother 2011; 45:1094-102. [DOI: 10.1345/aph.1q147] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Maryann R Cooper
- Massachusetts College of Pharmacy and Health Sciences, Worcester/Manchester, MA
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26
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Urgences chez le patient atteint de cancer. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Klastersky J, Awada A, Paesmans M, Aoun M. Febrile neutropenia: A critical review of the initial management. Crit Rev Oncol Hematol 2011; 78:185-94. [DOI: 10.1016/j.critrevonc.2010.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 03/10/2010] [Accepted: 03/24/2010] [Indexed: 11/28/2022] Open
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Teuffel O, Amir E, Alibhai S, Beyene J, Sung L. Cost effectiveness of outpatient treatment for febrile neutropaenia in adult cancer patients. Br J Cancer 2011; 104:1377-83. [PMID: 21468048 PMCID: PMC3101923 DOI: 10.1038/bjc.2011.101] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND There is uncertainty whether low-risk episodes of febrile neutropaenia (FN) in adult cancer patients are best managed in the in- or outpatient setting. METHODS A Monte Carlo cost-utility model was created to compare four treatment strategies for low-risk FN: (1) treatment in hospital with intravenous antibiotics (HospIV); (2) early discharge after 48 h in-patient observation, followed by oral outpatient treatment (EarlyDC); (3) outpatient management with IV antibiotics (HomeIV); and (4) outpatient management with oral antibiotics (HomePO). The model used a health-care payer perspective and a time horizon of one FN episode. Outcome measures were quality-adjusted FN episodes (QAFNE), costs (Canadian dollars) and incremental cost-effectiveness ratios (ICER). Parameter uncertainty was assessed with probabilistic sensitivity analyses. RESULTS HomePO was cost saving ($3470 vs $4183), but less effective (0.65 QAFNE vs 0.72 QAFNE) than HomeIV. The corresponding ICER was $10,186 per QAFNE. Both EarlyDC ($6115; 0.66 QAFNE) and HospIV ($13,557; 0.62 QAFNE) were dominated strategies. At a willingness-to-pay (WTP) threshold of $4,000 per QAFNE, HomePO and HomeIV were cost effective in 54 and 38% of simulations, respectively. INTERPRETATION For adult cancer patients with an episode of low-risk FN, treatment in hospital is more expensive and less effective than outpatient strategies.
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Affiliation(s)
- O Teuffel
- Division of Haematology/Oncology, Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M6G 1X8
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Rivas-Ruiz R, Villasis-Keever M, Miranda-Novales MG. Outpatient treatment for patients with cancer who develop a low-risk febrile neutropenic event. Hippokratia 2011. [DOI: 10.1002/14651858.cd009031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rodolfo Rivas-Ruiz
- Insitiuto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI; Hospital de Pediatra. Avenida Cuauhtemoc #330 Colonia Doctores Mexico
| | - Miguel Villasis-Keever
- Instituto Mexicano del Seguro Social; Clinical Epidemiology Research Unit; Mexico City DF Mexico CP 06470
| | - Maria G Miranda-Novales
- Centro Medico Nacional Siglo XXI; Hospital de Pediatra Avenida Cuauhtemoc #330 Colonia Doctores Mexico
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Teuffel O, Ethier MC, Alibhai SMH, Beyene J, Sung L. Outpatient management of cancer patients with febrile neutropenia: a systematic review and meta-analysis. Ann Oncol 2011; 22:2358-2365. [PMID: 21363878 DOI: 10.1093/annonc/mdq745] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In some centers, outpatient management for cancer patients with low-risk febrile neutropenia (FN) has been implemented into routine clinical practice. Our objective was to evaluate the current level of evidence before supporting widespread adoption of outpatient management for this population. METHODS We systematically reviewed randomized controlled trials evaluating efficacy and safety of outpatient management of FN. RESULTS From 1448 reviewed articles, 14 studies were included for meta-analysis. (i) Inpatient versus outpatient setting (6 studies) was not significantly associated with treatment failure [risk ratio 0.81; 95% confidence interval (CI) 0.55-1.19; P = 0.28]. Death occurred in 13 of 742 FN episodes with no difference between the two groups (risk ratio 1.11; 95% CI 0.41-3.05; P = 0.83). (ii) Outpatient oral versus outpatient parenteral antibiotics (8 studies) were similarly efficacious with no association between route of drug administration and treatment failure (risk ratio 0.93; 95% CI 0.65-1.32; P = 0.67). No death occurred in 857 FN episodes. CONCLUSION Based on the current literature, outpatient treatment of FN is a safe and efficacious alternative to inpatient management. Variation between studies in terms of time to discharge, choice of antibiotic class, and age of study population may limit the interpretation of the data.
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Affiliation(s)
- O Teuffel
- Division of Haematology/Oncology; Child Health Evaluative Sciences, The Hospital for Sick Children
| | - M C Ethier
- Child Health Evaluative Sciences, The Hospital for Sick Children
| | - S M H Alibhai
- Department of Health Policy Management and Evaluation, University of Toronto; Department of Medicine, University Health Network
| | - J Beyene
- Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Health Policy Management and Evaluation, University of Toronto; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - L Sung
- Division of Haematology/Oncology; Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Health Policy Management and Evaluation, University of Toronto.
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Worth LJ, Lingaratnam S, Taylor A, Hayward AM, Morrissey S, Cooney J, Bastick PA, Eek RW, Wei A, Thursky KA. Use of risk stratification to guide ambulatory management of neutropenic fever. Intern Med J 2011; 41:82-9. [DOI: 10.1111/j.1445-5994.2010.02339.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ha YE, Song JH, Kang WK, Peck KR, Chung DR, Kang CI, Joung MK, Joo EJ, Shon KM. Clinical factors predicting bacteremia in low-risk febrile neutropenia after anti-cancer chemotherapy. Support Care Cancer 2010; 19:1761-7. [DOI: 10.1007/s00520-010-1017-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 09/28/2010] [Indexed: 01/09/2023]
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Mebis J, Goossens H, Berneman ZN. Antibiotic management of febrile neutropenia: current developments and future directions. J Chemother 2010; 22:5-12. [PMID: 20227985 DOI: 10.1179/joc.2010.22.1.5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Mortality due to febrile neutropenia has decreased since the concept of empiric therapy became standard care. However, infectious complications remain the most common adverse events of chemotherapy. bacterial epidemiology has changed during the past decades. There is currently an increasing trend in infections due to Gramnegative bacteria which have higher rates of resistance for a variety of reasons.The use of biomarkers for diagnosis remains a domain of further investigation. Since the patient population with febrile neutropenia is very heterogeneous, models of risk assessment have been developed with the most commonly used today being the mASCC score.Oral antibiotic treatment seems to be appropriate in low-risk patients. In moderate or high-risk patients monotherapy is the most common option. However, due to emerging resistance this could change by next year. Some new antibiotics have been developed, but experience in the treatment of neutropenic fever is limited. The use of antibiotics for prophylaxis remains controversial, although recent studies suggest a reduction in death from all causes.
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Affiliation(s)
- J Mebis
- Division of Hematology, Antwerp University Hospital, Edegem Belgium.
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Seftel MD. Controversies in the management of fever in the neutropenic cancer patient. Transfus Apher Sci 2010; 42:151-6. [PMID: 20106722 DOI: 10.1016/j.transci.2010.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The febrile neutropenic episode (FNE) constitutes a medical emergency, primarily because of the attendant risks of overwhelming infection and death. Infection, particularly bacterial in nature, is the most important cause of FNE, although there are other potential causes that depend on host, disease, and therapy related factors. The spectrum of microbiological pathogens varies both temporally and geographically, rendering it difficult to provide universal recommendations for antimicrobial therapy in FNE. Nonetheless, there are unifying principles in the management of FNE that are helpful in guiding therapeutic decisions. Using a case-based approach in a patient with lymphoma, the following controversies regarding the management of FNE are discussed: the role of prophylactic anti-bacterial antimicrobials, the management of febrile patients in the out-patient setting, and the choice of initial antimicrobials.
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Affiliation(s)
- Matthew D Seftel
- Section of Haematology/Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Abstract
Objectives: The purpose of this study was to identify independent factors that can be
used to predict whether febrile neutropenic patients who appear healthy at
presentation will develop subsequent complications, using variables that are
readily available in the emergency department (ED). Method: The medical records of 192 episodes in which the patients presented to the ED
with neutropenic fever resulting from chemotherapy, with an alert mental
state and haemodynamic stability were retrospectively reviewed. Endpoints
examined were fever response to administered antibiotics, death or severe
medical complications during hospitalisation. Results: Thirty-eight episodes of neutropenic fever with complicated outcomes were
identified from among a total of 192 episodes. Three parameters emerged as
independent factors for the prediction of neutropenic fever with
complications in the multivariate regression analysis: platelet count
(130−450 × 103
cells/mm3) <50 000 cells/mm3, serum
C-reactive protein (CRP, 0.1–1 mg/dl)
>10 mg/dl and pulmonary infiltration on chest x
ray. Conclusions: Platelet count, CRP and pulmonary infiltration on chest x
ray at presentation could be used to identify febrile neutropenic patients
who will develop complications, and these factors may be useful in making
treatment-related decisions in the ED.
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Affiliation(s)
- J M Moon
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, South Korea
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Rolston KVI, Frisbee-Hume SE, Patel S, Manzullo EF, Benjamin RS. Oral moxifloxacin for outpatient treatment of low-risk, febrile neutropenic patients. Support Care Cancer 2009; 18:89-94. [PMID: 19387695 DOI: 10.1007/s00520-009-0634-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 03/30/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Low-risk febrile neutropenic patients can be treated without hospitalization with oral antibiotic regimens. Combination regimens are recommended. Our objective was to evaluate the feasibility of quinolone monotherapy (moxifloxacin) in this setting. METHODS In this open-label pilot study, eligible low-risk febrile neutropenic patients identified using pre-defined criteria (MASCC Risk Index) received oral moxifloxacin (400 mg) in our emergency center and were discharged after a 4-8 h observation period to ensure clinical stability. They subsequently received moxifloxacin 400 mg daily as outpatients. Success of monotherapy, outpatient management, the development of adverse events, and major medical complications were recorded. RESULTS The trial was closed without reaching the target sample size of 40 patients due to slow accrual. Twenty-one evaluable patients were enrolled, with sarcoma and breast cancer being the predominant underlying neoplasms. Most patients (76%) were severely neutropenic (</=100 cells/mm(3)) on enrollment. There were 13 episodes (62%) of unexplained fever and eight documented infections including five episodes (24%) of bacteremia. The overall success rate of monotherapy was 95%. One patient with unexplained fever and persistent neutropenia required hospitalization and responded to alternative therapy. No significant toxicity or severe medical complications occurred. CONCLUSIONS Oral outpatient quinolone monotherapy for low-risk febrile neutropenic patients appears feasible and needs to be formally evaluated in large randomized clinical trials.
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Affiliation(s)
- Kenneth V I Rolston
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. (Unit 1460), Houston, TX 77030, USA.
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