New strategies in the treatment of infectious complications in haematology and oncology: is there a role for out-patient antibiotic treatment of febrile neutropenia?
Febrile neutropenia is associated with a significant risk of complications and mortality. Patients with neutropenia secondary to cytostatic chemotherapy who develop fever are normally admitted to hospital and treated promptly with broad-spectrum antibiotics. Over the last 10 years, chemotherapy for solid tumours has been shifting out of the hospital setting into the ambit of community-based oncologists, and out-patient treatment with complex multidrug protocols is becoming increasingly common. In North America high-dose protocols combined with peripheral blood stem cell transfusion are already being administered on an out-patient basis. With the increase in the numbers of out-patients undergoing multidrug chemotherapy, there has been a corresponding rise in the severity and duration of neutropenia and in the incidence of associated infections. Patients with neutropenia of short duration (<7 days) and fever are at a relatively low risk for complications, and in these circumstances, out-patient antibiotic treatment is an alternative to costly hospitalisation. Drugs, whose antimicrobial coverage and pharmacokinetics make them particularly suitable for out-patient treatment of febrile neutropenia, include intravenous and oral quinolones and, for once-daily dosing, intravenous glycopeptides, ceftriaxone and intravenous aminoglycosides. Response rates of 60-95% have been achieved with such regimens in clinical trials, with hospital admission avoided in 75-95% of the cases. There is no doubt that out-patient treatment improves the quality of life of cancer patients. In Europe, however, there is a need for randomised clinical trials to support the establishment of out-patient-based treatment of febrile neutropenia. Out-patient antibiotic treatment of febrile neutropenia is still not standard practice, and community-based providers of such treatment must be adequately equipped and experienced in the management of this condition.
Department of Haematology and Oncology, Hannover Medical School, Hannover, Germany.
M
M
Karthaus
J
J
Carratalà
H
H
Jürgens
A
A
Ganser
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D005334:Fever / Q000188:drug therapy* / Q000209:etiology; D019337:Hematologic Neoplasms / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007239:Infections / Q000188:drug therapy* / Q000209:etiology*; D009369:Neoplasms / Q000150:complications* / Q000188:drug therapy; D009503:Neutropenia / Q000139:chemically induced / Q000150:complications* / Q000188:drug therapy*; D010045:Outpatients
D000900:Anti-Bacterial Agents; D000970:Antineoplastic Agents