Outpatient management of febrile neutropenia associated with cancer chemotherapy: Risk stratification and treatment review

• Published in: American journal of health-system pharmacy 2015-04, Vol.72 (8), p.619-631
• Main Authors: PHERWANI, NISHA, GHAYAD, JOANNA M, HOLLE, LISA M, KARPIUK, EMILIE L
• Format: Article
• Language: English
• Subjects: Ambulatory care; Ambulatory Care - methods; Ambulatory Care - standards; Anti-Bacterial Agents - therapeutic use; Antineoplastic Agents - adverse effects; Care and treatment; Chemotherapy; Clinical Trials as Topic - methods; Complications and side effects; Disease Management; Febrile Neutropenia - chemically induced; Febrile Neutropenia - diagnosis; Febrile Neutropenia - therapy; Health aspects; Humans; Methods; Neutropenia; Risk Assessment; Risk factors; Risk management; Treatment Outcome
• ISSN: 1079-2082; 1535-2900
• DOI: 10.2146/ajhp140194

PURPOSEStrategies for the management of chemotherapy-induced febrile neutropenia (FN), including assessment tools for determining which patients are at low risk for FN complications and can be treated in the outpatient setting, are discussed. SUMMARYDue to the potential for life-threatening complications, the development of FN in patients receiving cancer chemotherapy traditionally prompted hospitalization and i.v. antimicrobial therapy, but there is convincing published evidence that an identifiable subset of patients can be safely treated as outpatients. Two validated assessment tools recommended for identifying patients at low risk for FN complications are the Talcott classification system and the Multinational Association for Supportive Care in Cancer (MASCC) risk index; the MASCC index is superior in terms of sensitivity and negative predictive value but has lower specificity. In low-risk FN cases, outpatient oral antimicrobial therapy has been shown to be a safe and effective alternative to i.v. therapy for both inpatients and outpatients; current practice guidelines recommend an oral fluoroquinolone (e.g., ciprofloxacin) in combination with oral amoxicillin–clavulanate. The guidelines emphasize that in certain cases of FN (e.g., those involving prolonged or pronounced neutropenia or serious comorbidities), inpatient i.v. therapy is required. CONCLUSIONPharmacists can play an important role in the management of chemotherapy-associated FN through involvement in risk assessment to identify candidates for outpatient oral antimicrobial therapy, selection of appropriate pharmacotherapy, drug therapy monitoring, and development of institutional guidelines or pathways.