scholarly journals Evaluation of a Safe Neutrophil Count for Cessation of IV Antibiotics and Early Hospital Discharge in Stable, Afebrile Patients Recovering after Acute Myeloid Leukaemia (AML) Therapy or an Autograft

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 24-25
Author(s):  
Chih-Chiang Hu ◽  
Rakhee Subramanian ◽  
Andrew Grigg
Keyword(s):  
Hospital Discharge ◽  
Neutrophil Count ◽  
Conflicts Of Interest ◽  
Early Discharge ◽  
Recurrent Fever ◽  
High Dose ◽  
Oral Antibiotics ◽  
Post Discharge ◽  
Early Hospital Discharge ◽  
Haematology Patients

Background Currently there are no guidelines on a safe neutrophil count for intravenous antibiotic (IVAB) cessation and hospital discharge in haematology patients recovering after myelosuppressive chemotherapy complicated by febrile neutropenia (FN). Aims We assessed the safety in stable afebrile patients after recent FN of (i) appropriately stopping IVAB and (ii) early hospital discharge respectively within 24 hrs of absolute neutrophil count (ANC) recovery to ≥0.2x10^9/L. Appropriate cessation required a minimum of 3 days of IVAB and no focus of unresolved infection. Safety was defined as the absence of (i) fever recurrence after IVAB cessation and (ii) readmission in the 10-days post discharge for non-line related bacterial sepsis. Barriers to early discharge were also evaluated. Methods A retrospective, single centre audit on adult haematology patients admitted with AML (n=73 courses of induction or consolidation; 27 patients) or for an autograft (n=68 admissions;65 patients) between 2017-2019 and 2016-2017 respectively. Exclusion criteria included patients with secondary AML, reduced intensity AML chemotherapy (low dose cytarabine or azacitidine) and outpatient IVAB use post-discharge. Patients who continued on oral antibiotics as inpatients or on discharge were included in the analysis. Data were analysed with Mann Whitney U test, Chi square test and Fisher's exact test where appropriate. Results Both cohorts had a median age of 59 years. Autograft conditioning consisted mostly of high dose melphalan alone (57%) or with busulfan (7%) and BEAM (19%). All of the AML regimens contained either intermediate or high-dose cytarabine and/or an anthracycline. Most admissions (n=128; 91%) were complicated by FN, 32% (n=41) with positive blood cultures. Nearly half (n=61; 48%) of FN episodes ceased IVAB appropriately with 22/61 (36%) transitioned to oral antibiotics; another 19 (15%) episodes ceased IVAB prior to ANC ≥0.2. None of these 80 episodes had recurrent fever requiring IVAB resumption. IVAB were continued in the remaining 48 (37%) episodes, due to (a) unresolved fever (n=21) (b) recent bacteraemia or unresolved infective focus (n=17) or (c) empirically at physician discretion (n=10), for a median (range) duration of 3 (1-10), 3 (1-15) and 2 (1-5) days respectively. Thirty-seven (29%) of all FN episodes were discharged on oral antibiotics. Discharge within 24h from ANC≥0.2 occurred in 47% overall; more frequently in AML (60%) vs autograft (32%; p=0.001) patients, predominantly due to less unresolved gastrointestinal toxicity (5% vs 59% respectively). Other barriers to early discharge with an incidence of >5% included IVAB use, persistent fever, analgesia for mainly mucositis and transfusion requirement. Unplanned readmission rates were low (6% autograft, 3% AML) with none due to confirmed non-line related bacteraemia; these did not differ according to discharge ANC (≤0.5 or >0.5; p=0.217). Conclusion In afebrile, clinically stable AML and autograft patients without medico-social barriers to early discharge, IVAB can be ceased and hospital discharges safely done within 24h from recovery ANC≥0.2. Disclosures No relevant conflicts of interest to declare.

scholarly journals Early Switch From Intravenous to Oral Antibiotics and Early Hospital Discharge

1999 ◽  
Vol 159 (20) ◽  
pp. 2449 ◽  
Author(s):  
Julio A. Ramirez ◽  
Sergio Vargas ◽  
Gilbert W. Ritter ◽  
Michael E. Brier ◽  
Allie Wright ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Oral Antibiotics ◽  
Early Hospital Discharge

#35: Safety of Early Hospital Discharge of Neutropenic Pediatric Oncology Patients After Febrile Neutropenia

2021 ◽  
Vol 10 (Supplement_1) ◽  
pp. S16-S16
Author(s):  
Asia Castro ◽  
Miguel Minero ◽  
Martha Avilés-Robles
Keyword(s):  
Septic Shock ◽  
Febrile Neutropenia ◽  
Hospital Discharge ◽  
Antibiotic Treatment ◽  
Pediatric Oncology ◽  
Early Discharge ◽  
Infectious Complications ◽  
Oncology Patients ◽  
Early Hospital Discharge ◽  
The Mean

Abstract Background Cancer is one of the leading causes of death in children in Mexico. Infections are the main cause of morbidity and mortality in these patients. Febrile neutropenia (FN) constitutes an infectious emergency and early aggressive antibiotic treatment is the standard of care. Recent guidelines suggest discontinuing empirical antibiotics in patients who have negative blood cultures at 48 hours, who have been afebrile for at least 24 hours, and who have evidence of marrow recovery. Nevertheless, recommendations about discontinuing antibiotics and discharging patients while they are still neutropenic are less clear. We aimed to evaluate the safety of early hospital discharge of FN patients who are still neutropenic. Methods Observational, case–control study nested in a prospective cohort of pediatric oncology patients with FN at Hospital Infantil de México Federico Gómez (HIMFG) in Mexico City from May 2015 to September 2017. We defined early discharge as when a patient is discharged while neutropenic (ANC <500 cell/mm3) and has completed at least 7 days of antibiotics. Patients with FN who were discharged with neutropenia were defined as cases and patients with FN who were discharged after recovering from neutropenia were controls. To assess the safety of hospital early discharge, the following outcomes were analyzed until 7 days after discharge: new onset of fever, hospital readmission, need to restart antibiotic treatment, septic shock, and death. Descriptive statistics were performed with measures of central tendency. Variables of interest were compared with Pearson’s χ 2 or Student’s test. Results In total, 929 febrile neutropenia episodes were analyzed. The mean age was 7.5 years, 55.3% were female. Hematologic malignancies were the most frequent type of malignances in 50.8%. Acute lymphoblastic leukemia (ALL) was the underlying disease in 41%. Of the 929 FN episodes, 180 (19.3%) were discharged with neutropenia. Patients with ALL were the most frequent in 49.4%, followed by acute myeloid leukemia 18.8% and rhabdomyosarcoma 6.6%. Thirty-five percent were in maintenance therapy, 22% in remission induction therapy, and 9% in consolidation. 19.4% of discharged patients received granulocyte-colony stimulating factor. Ten patients (5.5%) were re-admitted during the 7 days following discharge. Six patients returned for chemotherapy administration and one was scheduled for liver biopsy. Three patients were re-admitted due to infectious complications (1.6%), none of them were under oral antibiotic treatment; two patients due to FN without microbiological isolation and one patient with septic shock due to multi-drug-resistant Pseudomonas aeruginosa. Older patients had a higher risk of readmission, with a mean age of 14.6 years (SD 4.6 years, 95% CI 7.7–21.6) (P = 0.01), compared with the mean of 7.7 years (SD 2.7 years, (95% CI 7.0, – 8.4) of patients who were not re-admitted. Conclusions In our population of pediatric patients with FN who were discharged before neutrophil recovery, readmission due to infectious complications was low (1.6%). Discharging patients with persistent neutropenia who are afebrile and had completed a course of antibiotics seems an acceptable practice with a low risk of readmission.

scholarly journals Mobilization and early hospital discharge for patients with acute myocardial infarction: literature review

2008 ◽  
Vol 21 (2) ◽  
pp. 345-350 ◽  
Author(s):  
Juliana de Lima Lopes ◽  
Juliana Turca dos Santos ◽  
Sheila Cristina de Lima ◽  
Alba Lúcia Bottura Leite de Barros
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Literature Review ◽  
Hospital Discharge ◽  
Early Mobilization ◽  
Bed Rest ◽  
Early Discharge ◽  
Early Hospital Discharge ◽  
Resting Period

OBJECTIVE: This study was a literature review with the purpose of analyzing articles comparing early and late mobilization and those comparing early and late discharge for patients with acute myocardial infarction. METHODS: The literature review was performed using the Lilacs and Medline databases (1966-2007), and the length of the resting period, the hospitalization and possible complications were analyzed. RESULTS: We selected 18 articles; 11 of them compared early and late mobilization and 7 compared early and late discharge. The length of the resting period in the early mobilization group varied from 2 to 10 days and 5 to 28 days for the longest resting period. The early discharge group stayed in the hospital from 3 to 14 days and the late discharge group stayed in the hospital from 5 to 21 days. CONCLUSION: The studies show that there is no evidence of complications related to short periods of bed rest and hospitalization.

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery

2017 ◽  
Vol 58 (5-6) ◽  
pp. 263-273 ◽  
Author(s):  
Marcos Pajarón-Guerrero ◽  
Manuel Francisco Fernández-Miera ◽  
Juan Carlos Dueñas-Puebla ◽  
Carmen Cagigas-Fernández ◽  
Iciar Allende-Mancisidor ◽  
...  
Keyword(s):  
Colorectal Surgery ◽  
Hospital Discharge ◽  
Laparoscopic Colorectal Surgery ◽  
Early Discharge ◽  
Care Model ◽  
Early Hospital Discharge ◽  
Discharge Care ◽  
The Mean ◽  
Hospital At Home

Background: To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. Methods: A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. Results: A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. Conclusions: For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Evaluation of high-dose methotrexate serum concentration requirement for discharge.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e19204-e19204
Author(s):  
Amulya Yellala ◽  
Prajwal Dhakal ◽  
Brooke Deason ◽  
Susanne Liewer ◽  
Avyakta Kallam ◽  
...  
Keyword(s):  
Sodium Bicarbonate ◽  
Supportive Care ◽  
Metastatic Breast ◽  
Retrospective Chart Review ◽  
Early Discharge ◽  
High Dose ◽  
Discharge Process ◽  
Post Discharge ◽  
Number Of Patients ◽  
Acute Complications

e19204 Background: Methotrexate (MTX) is used in high doses for the treatment of ALL, lymphoma, and metastatic breast cancer with CNS involvement. To avoid drug accumulation and mitigate toxicities caused by delayed clearance, patients (pts) are usually admitted to the hospital and standard supportive care with IV hydration, urinary alkalization, and leucovorin is provided and adjusted based on daily levels. Historically, a serum methotrexate level ≤ 0.05 µmol/L has been used to declare clearance and an ideal level for discharge based on studies conducted in the 1970s. We conducted a retrospective review in 2018 to identify frequency of supportive dose escalations required with MTX levels > 0.05 µmol/L. In 69 pts, 4 patients demonstrated delayed renal clearance and required supportive care escalations but all occurred at MTX levels > 0.3 µmol/L. This led to a proposed pilot discharge process once MTX was < 0.3 µmol/L to confirm the safety of earlier discharge. Methods: A retrospective chart review of pts with baseline CrCl ≥60 who received HD MTX between 07/2018 – 08/2019. Data collection included diagnosis, MTX discharge level, supportive care at discharge including PO Leucovorin and PO sodium bicarbonate and number of days supply, post-discharge complications (AKI, mucositis, fever, others). Primary outcome was the number of patients who required inpatient or outpatient supportive care for acute complications after being discharged with a methotrexate level ≥ 0.1 µmol/L. Descriptive statistics were used. Results: A total of 41 pts were included. Median age was 55 yrs (32-78), 25% were male. 73% were treated for DLBCL, median dose of MTX was 3500 mg/m2. Median MTX level at the time of discharge was 0.16 µmol/L (0.1-0.3 µmol/L). 12 pts were discharged with PO Leucovorin and 15 pts were discharged with both Leucovorin and PO Sodium bicarbonate with an average of 2 day’s supply. 1 acute complication of neutropenic fever requiring admission for inpatient antibiotics occurred which was felt to be unrelated to MTX level at discharge. Conclusions: This pilot suggests that pts can be safely discharged with MTX levels upto 0.3 µmol/L without acute complications. Results of this study will be used to a develop a standardized protocol outlining criteria for early discharge in select pts with MTX levels < 0.3 µmol/L to reduce length of stay, cost of hospitalization and improve patient satisfaction. [Table: see text]

scholarly journals 754. Evaluation of Standardized Dalbavancin Use to Facilitate Early Hospital Discharge for Patients Inappropriate for Outpatient Parenteral Antibiotic Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S336-S337 ◽  
Author(s):  
Katherine C Shihadeh ◽  
Heather Young ◽  
David L Wyles ◽  
Timothy C Jenkins
Keyword(s):  
Antibiotic Therapy ◽  
Hospital Discharge ◽  
Injection Drug Users ◽  
Drug Users ◽  
Medical Center ◽  
Cost Savings ◽  
Patient Discharge ◽  
Early Discharge ◽  
Early Hospital Discharge ◽  
Serious Infections

Abstract Background Patients frequently remain in the hospital for prolonged intravenous (IV) antibiotic therapy for serious infections when outpatient IV antibiotic therapy is unsafe or unfeasible. A protocol was developed to facilitate early discharge by administering one dose of dalbavancin 7 – 10 days prior to the planned end of treatment, allowing patient discharge the same day as the infusion. The purpose of this analysis was to describe the effectiveness, safety, and financial impact by using dalbavancin to facilitate early discharge. Methods This is a retrospective observational analysis of all inpatients who received dalbavancin at Denver Health Medical Center from April 2018 to April 2019. One dose of dalbavancin 1,500 mg was administered over 30 minutes to each patient. The medical record was reviewed 30 days after discharge to determine safety (adverse reaction to dalbavancin) and effectiveness (readmission or receipt of additional antibiotics). The estimated cost of one hospital day was $1,800; one dose of dalbavancin costs $3,000. Results Sixteen patients (69% male; average age 45 years) received dalbavancin. The majority of patients were homeless (81%), injection drug users (75%), and infected with HCV (56%). One patient was infected with HIV (6%) and none had diabetes, kidney disease, or cirrhosis. Antibiotics administered prior to dalbavancin were vancomycin or cefazolin, based on organism, for a median duration of 25 days (IQR 11–34). Patients were infected with methicillin-resistant S. aureus (n = 8), methicillin-susceptible S. aureus (n = 7), and one co-infection with S. epidermidis and S. pyogenes. The infections included complicated bacteremia (n = 6), uncomplicated bacteremia (n = 4), osteomyelitis (n = 2), right-sided endocarditis (n = 2), and osteomyelitis with bacteremia (n = 2). No adverse reactions were noted. Readmission 30 days from discharge occurred for two patients for reasons unrelated to the infection or dalbavancin. None received additional antibiotics. 115 hospital days were averted (average of 7 days per patient). Cost savings to the hospital were estimated to be $159,000. Conclusion A standardized approach to use dalbavancin for serious infections to facilitate early hospital discharge appears to be safe and effective and led to substantial cost savings. Disclosures All authors: No reported disclosures.

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