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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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Guram S, Vedi A. Managing febrile neutropenia in the UK in 2020. Arch Dis Child Educ Pract Ed 2022; 107:127-130. [PMID: 34083214 DOI: 10.1136/archdischild-2020-319886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/17/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Sheena Guram
- Department of Paediatric Haematology and Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aditi Vedi
- Department of Paediatric Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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Seneviratne N, Yeomanson D, Phillips R. Short-course antibiotics for chemotherapy-induced febrile neutropaenia: retrospective cohort study. Arch Dis Child 2020; 105:881-885. [PMID: 32184200 DOI: 10.1136/archdischild-2019-317908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/17/2020] [Accepted: 02/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent research in febrile neutropaenia (FN) has focused on reducing the intensity of treatment for those thought to be at low risk of significant morbidity or mortality. This has not led to a reduced burden of treatment for either families or healthcare systems. An alternative approach is to discharge all patients who remain well after 48 hours of inpatient treatment, either with no ongoing treatment or with appropriate antibiotics if the cultures are positive. This paper aimed to demonstrate that this approach is safe. METHODS Patients treated according to this approach in a single centre were reviewed retrospectively, with a random selection of patients from a 4-year period. Data were collected according to the Predicting Infectious Complications of Neutropenic sepsis in Children with Cancer dataset. In addition, all septic deaths over a 10-year period were reviewed in the same manner. RESULTS 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48-hour microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge. There were no septic deaths in this cohort.There were 11 deaths due to FN over the 10-year study period. Almost all patients were identified as severely unwell in the early stages of their final presentation or had a prolonged final illness. CONCLUSION This paper indicates that the policy described provides a balance between safety and acceptability. Further work is needed to demonstrate non-inferiority and cost-benefit.
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Affiliation(s)
- Nicola Seneviratne
- Haematology and Oncology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Daniel Yeomanson
- Haematology and Oncology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
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Sharing Roles and Control in Pediatric Low Risk Febrile Neutropenia: A Multicenter Focus Group Discussion Study Involving Patients, Parents, and Health Care Professionals. J Pediatr Hematol Oncol 2020; 42:337-344. [PMID: 32404685 DOI: 10.1097/mph.0000000000001827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Reducing treatment intensity for pediatric low risk febrile neutropenia may improve quality of life, and reduce hospital-acquired infections and costs. Key stakeholders' attitudes toward early discharge regimens are unknown. This study explored perceptions of reduced therapy regimens in the United Kingdom. MATERIALS AND METHODS Three study sites were purposively selected for their approaches to risk stratification, treatment protocols, shared care networks, and geographical spread of patients. Patients aged 13 to 18 years, parents of children of all ages and health care professionals participated in focus group discussions. A constant comparison analysis was used. RESULTS Thirty-two participants spoke of their different roles in managing febrile neutropenia and how these would change if reduced therapy regimens were implemented, how mutual trust would need to be strengthened and responsibility redistributed. Having identified a need for discretion and a desire for individualized care, negotiation within a spectrum of control allows achievement of the potential for realized discretion. Nonattendance exemplifies when control is different and families use their assessments of risk and sense of mutual trust, along with previous experiences, to make decisions. CONCLUSIONS The significance of shared decision making in improving patient experience through sharing risks, developing mutual trust, and negotiating control to achieve individualized treatment cannot be underestimated.
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Morgan JE. Fifteen minute consultation: Fever in children being treated for cancer. Arch Dis Child Educ Pract Ed 2019; 104:124-128. [PMID: 30104324 DOI: 10.1136/archdischild-2017-314718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 11/03/2022]
Abstract
Fever is a common symptom in children receiving treatment for cancer. Clinicians and families are most concerned about febrile neutropenia, though non-neutropenic fever often causes more challenging treatment dilemmas. This article provides a structured approach to the initial assessment, examination, investigation and risk assessment of children with fever during treatment for childhood cancer. Non-neutropenic fever in children with cancer is not well researched. There are no systematic reviews of its management and no National Institute for Health and Care Excellence (NICE) (or other international) guidance about what to do. Features to consider when managing non-neutropenic fever are discussed. Febrile neutropenia, meanwhile, is an oncological emergency and requires management using standard sepsis principles including administration of broad-spectrum antibiotics. Relevant NICE guidance provides a clear structure for treatment. Ongoing management depends on the response to initial treatment.
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Morgan JE, Phillips B, Stewart LA, Atkin K. Quest for certainty regarding early discharge in paediatric low-risk febrile neutropenia: a multicentre qualitative focus group discussion study involving patients, parents and healthcare professionals in the UK. BMJ Open 2018; 8:e020324. [PMID: 29764879 PMCID: PMC5961608 DOI: 10.1136/bmjopen-2017-020324] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES A systematic review of paediatric low-risk febrile neutropenia found that outpatient care is safe, with low rates of treatment failure. However, this review, and a subsequent meta-ethnography, suggested that early discharge of these patients may not be acceptable to key stakeholders. This study aimed to explore experiences and perceptions of patients, parents and healthcare professionals involved in paediatric febrile neutropenia care in the UK. SETTING Three different centres within the UK, purposively selected from a national survey on the basis of differences in their service structure and febrile neutropenia management. PARTICIPANTS Thirty-two participants were included in eight focus group discussions. PRIMARY OUTCOMES Experiences and perceptions of paediatric febrile neutropenia care, including possible future reductions in therapy. RESULTS Participants described a quest for certainty, in which they attempted to balance the uncertainty involved in understanding, expressing and negotiating risk with the illusion of certainty provided by strict protocols. Participants assessed risk using both formal and informal stratification tools, overlaid with emotional reactions to risk and experiences of risk within other situations. The benefits of certainty provided by protocols were counterbalanced by frustration at their strict constraints. The perceived benefits and harms of previous inpatient care informed participants' appraisals of future treatment strategies. CONCLUSIONS This study highlighted the previously underestimated harms of admission for febrile neutropenia and the paternalistic nature of decision making, along with the frustrations and challenges for all parties involved in febrile neutropenia care. It demonstrates how the same statistics, generated by systematic reviews, can be used by key stakeholders to interpret risk differently, and how families in particular can view the harms of therapeutic options as different from the outcomes used within the literature. It justifies a reassessment of current treatment strategies for these children and further exploration of the potential to introduce shared decision making.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Karl Atkin
- Department of Health Sciences, University of York, York, UK
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Maxwell RR, Egan-Sherry D, Gill JB, Roth ME. Management of chemotherapy-induced febrile neutropenia in pediatric oncology patients: A North American survey of pediatric hematology/oncology and pediatric infectious disease physicians. Pediatr Blood Cancer 2017; 64. [PMID: 28748605 DOI: 10.1002/pbc.26700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chemotherapy-induced febrile neutropenia (FN) is traditionally managed with hospital admission for parenteral antibiotics until neutropenia resolves. Recent studies have explored risk stratification and the safety of managing "low-risk" patients as outpatients. Few studies have directly assessed pediatric provider preferences for managing FN. PROCEDURE We conducted a survey of practicing US and Canadian pediatric hematology/oncology (PHO) and pediatric infectious disease (PID) physicians to assess their FN management preferences using case scenarios with varying risk profiles. RESULTS Twenty-one percent (n = 186) of PHO and 32% (n = 123) of PID physicians completed the survey. Overall, both groups of providers agreed regarding which patients with FN could be managed outpatient. For a child with acute lymphoblastic leukemia receiving maintenance chemotherapy with an absolute neutrophil count (ANC) of 400 cells/μl, 35% (n = 66) of PHO and 49% (n = 60) of PID physicians would consider outpatient management (P = 0.02). Of those physicians selecting inpatient management, 41% (n = 49) of PHO and 52% (n = 33) of PID physicians would be willing to discharge the patient without an increase in ANC, if afebrile with a negative blood culture (P = 0.16). For a similar patient with an ANC of 100 cells/μl, only 23% (n = 35) of PHO and 42% (n = 39) of PID physicians would consider discharge without an increase in ANC (P = 0.002). CONCLUSIONS Despite the lack of established guidelines for low-risk pediatric FN, a significant proportion of North American physicians report willingness to modify traditional management. This reinforces the need for evidence-based low-risk criteria and outpatient management guidelines to optimize consistency of care for these patients.
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Affiliation(s)
- Rochelle R Maxwell
- Division of Pediatric Hematology/Oncology, Children's Hospital at Montefiore, Bronx, New York
| | - Dana Egan-Sherry
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan B Gill
- Division of Pediatric Hematology/Oncology, Children's Hospital at Montefiore, Bronx, New York.,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Michael E Roth
- Division of Pediatric Hematology/Oncology, Children's Hospital at Montefiore, Bronx, New York.,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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8
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Phillips RS, Sung L, Amman RA, Riley RD, Castagnola E, Haeusler GM, Klaassen R, Tissing WJE, Lehrnbecher T, Chisholm J, Hakim H, Ranasinghe N, Paesmans M, Hann IM, Stewart LA. Predicting microbiologically defined infection in febrile neutropenic episodes in children: global individual participant data multivariable meta-analysis. Br J Cancer 2016; 114:623-30. [PMID: 26954719 PMCID: PMC4800297 DOI: 10.1038/bjc.2016.28] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Risk-stratified management of fever with neutropenia (FN), allows intensive management of high-risk cases and early discharge of low-risk cases. No single, internationally validated, prediction model of the risk of adverse outcomes exists for children and young people. An individual patient data (IPD) meta-analysis was undertaken to devise one. METHODS The 'Predicting Infectious Complications in Children with Cancer' (PICNICC) collaboration was formed by parent representatives, international clinical and methodological experts. Univariable and multivariable analyses, using random effects logistic regression, were undertaken to derive and internally validate a risk-prediction model for outcomes of episodes of FN based on clinical and laboratory data at presentation. RESULTS Data came from 22 different study groups from 15 countries, of 5127 episodes of FN in 3504 patients. There were 1070 episodes in 616 patients from seven studies available for multivariable analysis. Univariable analyses showed associations with microbiologically defined infection (MDI) in many items, including higher temperature, lower white cell counts and acute myeloid leukaemia, but not age. Patients with osteosarcoma/Ewings sarcoma and those with more severe mucositis were associated with a decreased risk of MDI. The predictive model included: malignancy type, temperature, clinically 'severely unwell', haemoglobin, white cell count and absolute monocyte count. It showed moderate discrimination (AUROC 0.723, 95% confidence interval 0.711-0.759) and good calibration (calibration slope 0.95). The model was robust to bootstrap and cross-validation sensitivity analyses. CONCLUSIONS This new prediction model for risk of MDI appears accurate. It requires prospective studies assessing implementation to assist clinicians and parents/patients in individualised decision making.
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Affiliation(s)
- Robert S Phillips
- Centre for Reviews and Dissemination, University of York, York, UK,Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK,E-mail:
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roland A Amman
- Department of Pediatrics, University of Bern, Bern, Switzerland
| | - Richard D Riley
- Department of Primary Care and Health Sciences, Keele University, Keele, UK
| | | | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia,Department of Paediatric Infectious Diseases and The Paediatric Integrated Cancer Service, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Robert Klaassen
- Department of Pediatrics, Division of Hematology/Oncology, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Wim J E Tissing
- Department of Pediatric Oncology, University Of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Julia Chisholm
- Department of Childrens and Young Peoples Oncology, Royal Marsden Hospital, Sutton, Surrey, London, UK
| | - Hana Hakim
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Neil Ranasinghe
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Marianne Paesmans
- EORTC Data Centre and Hopitaux Universitaires Bordet-Erasme—Institut Jules Bordet, Brussels, Belgium
| | - Ian M Hann
- Institute of Child Health and Great Ormond Street Childrens Hospital, London, UK
| | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
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9
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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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10
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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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Gibson F, Chisholm J, Blandford E, Donachie P, Hartley J, Lane S, Selwood K, Skinner R, Phillips R. Developing a national ‘low risk’ febrile neutropenia framework for use in children and young people's cancer care. Support Care Cancer 2012; 21:1241-51. [DOI: 10.1007/s00520-012-1653-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 10/29/2012] [Indexed: 11/24/2022]
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Sive J, Ardeshna KM, Cheesman S, le Grange F, Morris S, Nicholas C, Peggs K, Statham P, Goldstone AH. Hotel-based ambulatory care for complex cancer patients: a review of the University College London Hospital experience. Leuk Lymphoma 2012; 53:2397-404. [PMID: 22591143 DOI: 10.3109/10428194.2012.694430] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Since 2005, University College London Hospital (UCLH) has operated a hotel-based Ambulatory Care Unit (ACU) for hematology and oncology patients requiring intensive chemotherapy regimens and hematopoietic stem cell transplants. Between January 2005 and 2011 there were 1443 patient episodes, totaling 9126 patient days, with increasing use over the 6-year period. These were predominantly for hematological malignancy (82%) and sarcoma (17%). Median length of stay was 5 days (range 1-42), varying according to treatment. Clinical review and treatment was provided in the ACU, with patients staying in a local hotel at the hospital's expense. Admission to the inpatient ward was arranged as required, and there was close liaison with the inpatient team to preempt emergency admissions. Of the 523 unscheduled admissions, 87% occurred during working hours. An ACU/hotel-based treatment model can be safely used for a wide variety of cancers and treatments, expanding hospital treatment capacity, and freeing up inpatient beds for those patients requiring them.
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Affiliation(s)
- Jonathan Sive
- Department of Haematology, University College London Hospital, London, UK.
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13
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Diorio C, Martino J, Boydell KM, Ethier MC, Mayo C, Wing R, Teuffel O, Sung L, Tomlinson D. Parental perspectives on inpatient versus outpatient management of pediatric febrile neutropenia. J Pediatr Oncol Nurs 2012; 28:355-62. [PMID: 22194148 DOI: 10.1177/1043454211418665] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To describe parent preference for treatment of febrile neutropenia and the key drivers of parental decision making, structured face-to-face interviews were used to elicit parent preferences for inpatient versus outpatient management of pediatric febrile neutropenia. Parents were presented with 4 different scenarios and asked to indicate which treatment option they preferred and to describe reasons for this preference during the face-to-face interview. Comments were recorded in writing by research assistants. A consensus approach to thematic analysis was used to identify themes from the written comments of the research assistants. A total of 155 parents participated in the study. Of these, 80 (51.6%) parents identified hospital-based intravenous treatment as the most preferred treatment scenario for febrile neutropenia. The major themes identified included convenience/disruptiveness, physical health, emotional well-being, and modifiers of parental decision making. Most parents preferred hospital-based treatment for febrile neutropenia. An understanding of issues that influence parental decision making may assist health care workers in planning program implementation and further support families in their decision-making process.
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Phillips RS, Sutton AJ, Riley RD, Chisholm JC, Picton SV, Stewart LA. Predicting infectious complications in neutropenic children and young people with cancer (IPD protocol). Syst Rev 2012; 1:8. [PMID: 22588015 PMCID: PMC3351734 DOI: 10.1186/2046-4053-1-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 02/09/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A common and potentially life-threatening complication of the treatment of childhood cancer is infection, which frequently presents as fever with neutropenia. The standard management of such episodes is the extensive use of intravenous antibiotics, and though it produces excellent survival rates of over 95%, it greatly inconveniences the three-fourths of patients who do not require such aggressive treatment. There have been a number of studies which have aimed to develop risk prediction models to stratify treatment. Individual participant data (IPD) meta-analysis in therapeutic studies has been developed to improve the precision and reliability of answers to questions of treatment effect and recently have been suggested to be used to answer questions regarding prognosis and diagnosis to gain greater power from the frequently small individual studies. DESIGN In the IPD protocol, we will collect and synthesise IPD from multiple studies and examine the outcomes of episodes of febrile neutropenia as a consequence of their treatment for malignant disease. We will develop and evaluate a risk stratification model using hierarchical regression models to stratify patients by their risk of experiencing adverse outcomes during an episode. We will also explore specific practical and methodological issues regarding adaptation of established techniques of IPD meta-analysis of interventions for use in synthesising evidence derived from IPD from multiple studies for use in predictive modelling contexts. DISCUSSION Our aim in using this model is to define a group of individuals at low risk for febrile neutropenia who might be treated with reduced intensity or duration of antibiotic therapy and so reduce the inconvenience and cost of these episodes, as well as to define a group of patients at very high risk of complications who could be subject to more intensive therapies. The project will also help develop methods of IPD predictive modelling for use in future studies of risk prediction.
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Affiliation(s)
- Robert S Phillips
- Centre for Reviews and Dissemination, Alcuin College, University of York, York, YO10 5DD, UK.
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15
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Elevated serum cytokine levels using cytometric bead arrays predict culture-positive infections in childhood oncology patients with febrile neutropenia. J Pediatr Hematol Oncol 2012; 34:e36-8. [PMID: 22215102 DOI: 10.1097/mph.0b013e3182193009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neutropenic patients with bacteraemia need prolonged intravenous antibiotic treatment. Using cytometric bead array technology, we show in children with febrile neutropenia that bacteraemia is associated with an elevation of at least 1 of 3 plasma cytokines plus C-reactive protein. The combination of interleukin (IL)-8, IL-6, IL-10, and C-reactive protein values above operator-defined cutoff levels identified 15 of 16 episodes of bacteraemia, making this a potentially useful technique in identifying high-risk patients who should not be discharged early from hospital. Furthermore, low risk of bacteraemia may be predicted by a combination of below threshold cytokines and negative clinical examination.
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17
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Chemotherapy outpatients' unplanned presentations to hospital: a retrospective study. Support Care Cancer 2010; 19:963-9. [PMID: 20499108 DOI: 10.1007/s00520-010-0913-y] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 05/11/2010] [Indexed: 01/12/2023]
Abstract
GOAL OF WORK This descriptive, retrospective study sought to identify the nature and magnitude of chemotherapy outpatients' unplanned presentations and admissions to the emergency department and/or cancer centre at a large metropolitan tertiary hospital, and to explore the antecedents to those presentations. PATIENTS AND METHODS Retrospective data were collected for outpatients who made an unplanned presentation to a large metropolitan hospital in Sydney, Australia between October 1, 2006 and September 30, 2007. Detailed information was collected for those who had received cytotoxic chemotherapy at the hospital's cancer centre within the 6 months prior to the unplanned presentation to hospital. Demographic and explanatory variables were identified, including: reasons for presentation, cancer diagnosis, chemotherapy regimens, and position in the chemotherapy trajectory. MAIN RESULTS The Cancer Institute NSW figures indicate that each year approximately 518 outpatients are treated with chemotherapy at the participating cancer centre. During the study period, 316 cancer outpatients made 469 unplanned presentations to either the Cancer Centre or the hospital emergency department. Of those outpatients presented, 233 (73.7%) had received chemotherapy in the previous 6 months and made a total of 363 presentations. Of these 363 presentations, 253 (69.7%) occurred within 4 weeks of receiving chemotherapy. The majority of presentations by those who had received chemotherapy in the previous 6 months resulted in hospital admission (87.6%) for a median length of stay of 5 days. The most frequent presentation symptoms were nausea and/or vomiting (45.2%), pain (27%), fever and/or febrile neutropenia (23.4%), shortness of breath (19.3%), dehydration (12.1%), anaemia (8.8%), fatigue (8.8%), diarrhoea (8.8%), and anxiety and/or depression (5.5%). CONCLUSIONS Chemotherapy outpatients have significant unmet needs following treatment, indicating an urgent need for improved continuity of care and better integration of primary and tertiary health care services.
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Successful introduction and audit of a step-down oral antibiotic strategy for low risk paediatric febrile neutropaenia in a UK, multicentre, shared care setting. Eur J Cancer 2009; 45:2843-9. [DOI: 10.1016/j.ejca.2009.06.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 05/15/2009] [Accepted: 06/10/2009] [Indexed: 11/22/2022]
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Abstract
This review summarizes the current status and diagnostic-therapeutic challenges in febrile neutropenia. Patients with neutropenia-associated infections have a poor prognosis. A large meta-analysis of trials assessing prophylactic antibiotics has shown significant survival benefits; clinical significance of resistance is unclear. Administering broad-spectrum antibiotics to established febrile neutropenic patients has become selective, vancomycin is withheld unless absolutely necessary, and low-risk patients are identified with biological markers. Such patients are now managed with oral antibiotics at home or even without antibiotics. Protracted prolonged neutropenia is the setting par excellence for invasive fungal infections. Conventional amphotericin B administered to such risk patients reduces the incidence of fungal infections. New antifungal drugs have heightened efficacy and lowered toxicity. Novel antifungal diagnostic tests include imaging, particularly the CT "halo" sign (aspergillosis), and serology (glucan, galactomannan), and provide earlier diagnosis and treatment and better outcomes. Negative tests may indicate withholding antifungal therapy. High intermittent dosing of liposomal amphotericin B seems as safe and as effective as standard dosing regimens, but at half the drug acquisition cost. The use of nonantibiotic agents has offered alternative management strategies. Recombinant interleukin-11 reduces bacteremia, through a cytoprotective mechanism on the gut. rhIL-11 releases C-reactive protein and causes shedding of soluble TNF receptor-1, modulating the immunological milieu and the systemic inflammatory response. Other candidate molecules include RANTES and long-pentraxin 3. Recombinant growth factors reduce febrile episodes, permitting completion of chemotherapy, increase overall survival, and minimize infection mortality.
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Affiliation(s)
- Michael Ellis
- Department of Medicine, Faculty of Medicine and Health Sciences, Tawam-Johns Hopkins and Al Ain Hospitals, Al Ain, United Arab Emirates.
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Saini S, Rosoff PM. Are we finally ready for outpatient management of febrile neutropenia? Pediatr Blood Cancer 2007; 49:765-6. [PMID: 17514730 DOI: 10.1002/pbc.21224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Shermini Saini
- Department of Pediatrics, Division of Hematology and Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA
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