ASCO updates guidelines on outpatient management of fever, neutropenia

Clinical judgment should be used to determine which patients being treated for malignancy are eligible for outpatient management of fever and neutropenia, according to updated guidelines from ASCO and the Infectious Diseases Society of America.

Clinical criteria or validated tools can help clinicians make judgements. This updated guideline includes the addition of a new tool — Clinical Index of Stable Febrile Neutropenia (CISNE) — which can help determine if a patient is low risk.

Profound and prolonged neutropenia after chemotherapy can increase a patient’s risk for infection. Fever can be an important indicator of neutropenia and/or infection.

“Prevention and appropriate management of neutropenic fever syndromes is important, because the rate of major complications (eg, hypotension, acute renal, respiratory, heart failure) in the context of neutropenic fever syndromes is approximately 25% to 30%, and the mortality rate ranges up to 11%,” Randy A. Taplitz, MD, professor of medicine and chief of clinical services at UC San Diego School of Medicine, and colleagues wrote.

In this updated guideline, researchers included new evidence on risk stratification, as well as treatment recommendations for fever and neutropenia in the outpatient setting, and psychosocial and logistic recommendations. The update included six new or updated meta-analyses and six new primary studies.

Consistent with previous recommendations, the guidelines endorsed a recommendation for prompt patient assessment after presentation and administration of therapy within 1 hour of triage. Clinical judgment should be used to determine which patients can be managed with outpatient therapy. Clinicians can use tools — such as the Multinational Association of Support Care in Cancer risk index, Talcott’s rules or CISNE — to determine patient risk.

“The CISNE can be used in the population of patients with neutropenic fever syndromes who appear to be stable after chemotherapy for treatment of solid tumors,” the researchers wrote. “The CISNE can improve classification of this low-risk group of patients, relative to tools that have been previously endorsed.”

Cardiovascular, hematologic, gastrointestinal, infectious and renal factors should also be considered.

When determining if patients can be effectively managed in the outpatient setting, clinicians should evaluate:

distance from clinic or hospital;

willingness of primary care physician or oncologist to manage care;

access to clinic, caregiver/support and telephone; and

history of treatment compliance.

Patients should be treated with their first dose of empirical antimicrobial(s) in the clinic, ED or hospital and observed for at least 4 hours, according to the guidelines.

Patients who are low risk and respond to initial inpatient IV antibiotic treatment should be considered for outpatient treatment.

The guideline authors recommended treatment with an oral fluoroquinolone plus amoxicillin/clavulanate — or clindamycin, if penicillin allergic — for outpatient treatment. If patients do not respond to treatment within 2 to 3 days, they should be reevaluated and considered for hospitalization.

“The patient representative included in our expert panel highlighted the importance of communication between [oncologists, infectious disease specialists, emergency medicine physicians, nurses and advanced practice providers] and inpatients and outpatients regarding education about safety practices, what patients need to be aware of to communicate with clinicians, and expectations of patient and/or caregiver responsibility once the patient is discharged,” the researchers wrote. “Across the recommendations contained within this guideline, the patient representative highlighted that psychosocial and logistic requirements for outpatient management should be provided to patients and caregivers.” – by Cassie Homer

Disclosures: Taplitz reports a consulting/advisory role and expenses from Merck, as well as institutional funding from Chimerix. Please see the guideline for all other authors’ relevant financial disclosures.