Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy

American society of clinical oncology clinical practice guideline

Christopher R. Flowers, Jerome Seidenfeld, Eric J. Bow, Clare Karten, Charise Gleason, Douglas K. Hawley, Nicole M. Kuderer, Amelia A. Langston, Kieren Marr, Kenneth V I Rolston, Scott D. Ramsey

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)794-810
Number of pages17
JournalJournal of Clinical Oncology
Volume31
Issue number6
DOIs
StatePublished - Feb 20 2013

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Medical Oncology
Neutropenia
Practice Guidelines
Fever
Outpatients
Neoplasms
Fluoroquinolones
Mortality
Guidelines
Clavulanic Acid
Clindamycin
Triage
Amoxicillin
Therapeutics
Infection
Penicillins
Patient Selection
Inpatients
Neutrophils

ASJC Scopus subject areas

  • Cancer Research
  • Oncology

Cite this

Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy : American society of clinical oncology clinical practice guideline. / Flowers, Christopher R.; Seidenfeld, Jerome; Bow, Eric J.; Karten, Clare; Gleason, Charise; Hawley, Douglas K.; Kuderer, Nicole M.; Langston, Amelia A.; Marr, Kieren; Rolston, Kenneth V I; Ramsey, Scott D.

In: Journal of Clinical Oncology, Vol. 31, No. 6, 20.02.2013, p. 794-810.

Research output: Contribution to journalArticle

Flowers, Christopher R. ; Seidenfeld, Jerome ; Bow, Eric J. ; Karten, Clare ; Gleason, Charise ; Hawley, Douglas K. ; Kuderer, Nicole M. ; Langston, Amelia A. ; Marr, Kieren ; Rolston, Kenneth V I ; Ramsey, Scott D. / Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy : American society of clinical oncology clinical practice guideline. In: Journal of Clinical Oncology. 2013 ; Vol. 31, No. 6. pp. 794-810.
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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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AU - Karten, Clare

AU - Gleason, Charise

AU - Hawley, Douglas K.

AU - Kuderer, Nicole M.

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AU - Marr, Kieren

AU - Rolston, Kenneth V I

AU - Ramsey, Scott D.

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