Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study

Purpose To compare outcome and cost of ambulatory versus hospitalized management among febrile neutropenic children at low risk for invasive bacterial infection (IBI). Patients and Methods Children presenting with febrile neutropenia at six hospitals in Santiago, Chile, were categorized as high or low risk for IBI. Low-risk children were randomly assigned after 24 to 36 hours of hospitalization to receive ambulatory or hospitalized treatment and monitored until episode resolution. Outcome and cost were determined for each episode and compared between both groups using predefined definitions and questionnaires. Results A total of 161 (41%) of 390 febrile neutropenic episodes evaluated from June 2000 to February 2003 were classified as low risk, of which 149 were randomly assigned to ambulatory (n = 78) or hospital-based (n = 71) treatment. In both groups, mean age (ambulatory management, 55 months; hospital-based management, 66 months), sex, and type of cancer were similar. Outcome was favorable in 74 (95%) of 78 ambulatory-treated children and 67 (94%) of 71 hospital-treated children (P = NS). Mean cost of an episode was US $638 (95% CI, $572 to $703) and US $903 (95% CI, $781 to $1,025) for the ambulatory and hospital-based groups, respectively (P = .003). Conclusion For children with febrile neutropenia at low risk for IBI, ambulatory management is safe and significantly cost saving compared with standard hospitalized therapy.

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1586 Oral vs intravenous antibiotics in low risk paediatric febrile neutropenia: A meta-analysis of randomised controlled trials

European Journal of Cancer ◽

10.1016/s0959-8049(16)30675-x ◽

2015 ◽

Vol 51 ◽

pp. S233

Author(s):

A. Vedi ◽

R. Cohn

Keyword(s):

Febrile Neutropenia ◽

Randomised Controlled Trials ◽

Meta Analysis ◽

Low Risk ◽

Controlled Trials ◽

Intravenous Antibiotics ◽

Randomised Controlled

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Emperical Oral Antibiotic Therapy for Children with Low Risk Febrile Neutropenia during Cancer Chemotherapy

Journal of Nepal Paediatric Society ◽

10.3126/jnps.v29i1.1596 ◽

1970 ◽

Vol 29 (1) ◽

pp. 22-25 ◽

Cited By ~ 3

Author(s):

PN Shrestha ◽

K Sah ◽

R Rana

Keyword(s):

Febrile Neutropenia ◽

Cancer Chemotherapy ◽

Empirical Therapy ◽

Low Risk ◽

Oral Antibiotic ◽

Oral Antibiotics ◽

Safe Alternative ◽

Oral Antibiotic Therapy ◽

Intravenous Antibiotics ◽

Risk Patients

Introduction: In patient with fever and neutropenia during cancer chemotherapy who have a low risk of complications, oral antibiotic may be an acceptable alternative to intravenous antibiotics. Methods: We conducted a prospective hospital based study to the patients who had fever and neutropenia during caner chemotherapy. Only low risk patients i.e. neutropenia of less than seven days, ANC >250/cmm, without any signs of shock were included in the study. All the patients were hospitalized and given oral antibiotics Ofloxacin and Amoxy-Clav and were closely observed until fever subsided for more than 48 hours and improved from neutropenia. Results: A total of 54 cases were enrolled in the study. Out of 54 patients two patients were lost, 8 needed IV antibiotics for different reasons and 44 patients (81%) improved well with oral antibiotics only. Conclusion: In hospitalized low risk patients who have fever and neutropenia, empirical therapy with oral ofloxacin and amoxy-clav may be a safe alternative to IV antibiotics. Key words: Febrile Neutropenia, Cancer Chemotherapy, ANC. doi:10.3126/jnps.v29i1.1596 J. Nepal Paediatr. Soc. Vol.29(1) p.22-25

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Oral Versus Intravenous Antibiotics in Low Risk Paediatric Febrile Netropenia: a Meta-Analysis of Randomised Controlled Trials

Annals of Oncology ◽

10.1093/annonc/mdu356.24 ◽

2014 ◽

Vol 25 ◽

pp. iv525

Author(s):

A. Vedi ◽

R.J. Cohn

Keyword(s):

Randomised Controlled Trials ◽

Meta Analysis ◽

Low Risk ◽

Controlled Trials ◽

Intravenous Antibiotics ◽

Randomised Controlled

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Cost-effectiveness of home-based care of febrile neutropenia in children with cancer

10.22541/au.163251882.21756689/v1 ◽

2021 ◽

Author(s):

Michelle Tew ◽

Richard De Abreu Lourenco ◽

Joshua Gordon ◽

Karin Thursky ◽

Monica Slavin ◽

...

Keyword(s):

Cost Effectiveness ◽

Febrile Neutropenia ◽

Low Risk ◽

Hospital Treatment ◽

Decision Analytic Model ◽

Children With Cancer ◽

Patient Level ◽

Home Based ◽

Intravenous Antibiotics ◽

Home Based Care

INTRODUCTION Home-based treatment of low-risk febrile neutropenia (FN) in children with cancer with oral or intravenous antibiotics is safe and effective. There are limited data on the economic impact of this model of care. We evaluated the cost-effectiveness of implementing a low-risk FN program, incorporating home-based intravenous antibiotics, in a tertiary pediatric hospital. METHODS A decision analytic model was constructed to compare costs and outcomes of the low-risk FN program, with usual in-hospital treatment with intravenous antibiotics. The program included a clinical decision rule to identify patients at low-risk for severe infection and home-based eligibility criteria using disease, chemotherapy and patient-level factors. Health outcomes (quality-of-life) and probabilities of FN risk classification and home-based eligibility were based on prospectively collected data. Patient-level costs were extracted from hospital records. Cost-effectiveness was expressed as the incremental cost per quality-adjusted life year (QALY). FINDINGS The mean healthcare cost of home-based FN treatment in low-risk patients was A$7,765 per patient compared to A$20,396 for in-hospital treatment (mean difference A$12,632 (95% CI,12,496-12,767)). Overall, the low-risk FN program was the dominant strategy, being more effective (0.0011 QALY (95% CI,0.0011-0.0012)) and less costly. Results of the model were most sensitive to proportion of children eligible for home-based care program. CONCLUSION Compared to in-hospital FN care, the low-risk FN program is cost-effective, with savings arising from cheaper cost of caring for children at home. These savings could increase as more patients eligible for home-based care are included in the program.

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Early Switch From Intravenous to Oral Antibiotics and Early Hospital Discharge

Archives of Internal Medicine ◽

10.1001/archinte.159.20.2449 ◽

1999 ◽

Vol 159 (20) ◽

pp. 2449 ◽

Cited By ~ 150

Author(s):

Julio A. Ramirez ◽

Sergio Vargas ◽

Gilbert W. Ritter ◽

Michael E. Brier ◽

Allie Wright ◽

...

Keyword(s):

Hospital Discharge ◽

Oral Antibiotics ◽

Early Hospital Discharge

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Early identification of patients at low risk of death after myocardial infarction and potentially suitable for early hospital discharge

BMJ ◽

10.1136/bmj.308.6935.1006 ◽

1994 ◽

Vol 308 (6935) ◽

pp. 1006-1010 ◽

Cited By ~ 17

Author(s):

R W Parson ◽

K D Jamrozik ◽

M S T Hobbs ◽

D L Thompson

Keyword(s):

Myocardial Infarction ◽

Hospital Discharge ◽

Early Identification ◽

Low Risk ◽

Early Hospital Discharge ◽

Risk Of Death

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Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia

Journal of Clinical Oncology ◽

10.1200/jco.20.00591 ◽

2020 ◽

Vol 38 (27) ◽

pp. 3150-3160

Author(s):

Adam J. Esbenshade ◽

Zhiguo Zhao ◽

Alaina Baird ◽

Emily A. Holmes ◽

Daniel E. Dulek ◽

...

Keyword(s):

High Risk ◽

Bloodstream Infection ◽

Risk Prediction ◽

Pediatric Patients ◽

Prediction Models ◽

Low Risk ◽

Severe Neutropenia ◽

Patients With Cancer ◽

Intravenous Antibiotics ◽

Pediatric Cancer Patients

PURPOSE Management of febrile pediatric patients with cancer with an absolute neutrophil count of 500/µL or greater is unclear. The Esbenshade Vanderbilt (EsVan) risk prediction models have been shown to predict bloodstream infection (BSI) likelihood in this population, and this study sought to prospectively validate and implement these models in clinical practice. METHODS Data were prospectively collected on febrile pediatric patients with cancer with a central venous catheter from April 2015 to August 2019 at a single site, at which the models (EsVan: 2015 to 2017; EsVan2: October 2017 to 2019) were initially developed and subsequently implemented for clinical management in well-appearing nonseverely neutropenic individuals. It was recommended that patients with low BSI risk (< 10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (> 40%) be admitted on broad-spectrum antibiotics. Seven-day outcomes were then collected and EsVan models were prospectively validated and C-statistics estimated. RESULTS In 937 febrile, nonsevere neutropenia episodes, frequencies of low-, intermediate-, and high-risk episodes were 88.9%, 8.6%, and 2.3% respectively. BSI incidence was 4.2% (39 of 937). Within risk groups, low-risk BSI incidence was 1.9% (16 of 834) with BSI incidence of 13.6% and 54.5% for intermediate- and high-risk episodes, respectively. Empirical intravenous antibiotics were administered in 21.1% of low-risk episodes at presentation and at 7 days postpresentation, 72.3% of episodes never required intravenous antibiotics. There were no deaths or clinical decompensations attributable to antibiotic delay. For BSI detection, EsVan and EsVan2 models applied to the new cohort achieved C-statistics of 0.802 and 0.824, respectively. CONCLUSION Prospective, real-time clinical utilization of the EsVan models accurately predicts BSI risk and safely reduces unnecessary antibiotic use in febrile, nonseverely neutropenic pediatric patients with cancer.

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