The feasibility of early hospital discharge with oral antimicrobial therapy in low risk patients with febrile neutropenia following chemotherapy for hematologic malignancies

Abstract

Background and objectives: It is now evident that patients experiencing febrile neutropenia induced by chemotherapy do not constitute a homogeneous group. With increasing accuracy it is now possible to identify low-risk patients for whom less intensive and more convenient treatment may be appropriate.

Design and methods: In a cohort of such patients with hematologic malignancies, we prospectively validated the usefulness of the risk-index of the Multinational Association of Supportive Care in Cancer (MASCC) in identifying patients at low risk for the development of serious medical complications. Moreover, we studied the feasibility and safety of early discharge of these low-risk patients 24 hours after fever defervescence with subsequent oral antibiotic therapy.

Results: Of the 279 episodes of febrile neutropenia included, 105 (38%) had a MASCC risk-index score indicating low risk. Serious complications were reported in connection with 111 (63%) high-risk and 16 (15%) low-risk episodes (p<0.0001). The risk-index identified low-risk patients with a specificity, sensitivity and positive predictive value of 87%, 58%, and 84%, respectively. A substantial proportion of the low-risk patients (36%) were considered ineligible for oral therapy, while the remaining 67 (64%) received oral antibiotic treatment following discharge from the hospital 24 hours after defervescence. Upon final evaluation, 64 of the discharged patients (95%) remained afebrile, only three required readmission and there was no mortality in this group.

Interpretation and conclusions: The MASCC risk-index is a valuable tool for identifying febrile neutropenic patients at low risk for complications. Oral antibiotic treatment following discharge from the hospital 24 hours after defervescence offers a safe and cost-effective alternative to the conventional management of carefully selected low-risk patients.