Antimicrobial Prophylaxis and Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology Clinical Practice Guideline

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

+ Author Affiliations

1. Christopher R. Flowers, Charise Gleason, and Amelia A. Langston, Emory University School of Medicine, Atlanta, GA; Jerome Seidenfeld, American Society of Clinical Oncology, Alexandria, VA; Eric J. Bow, CancerCare Manitoba and University of Manitoba, Winnipeg, Manitoba, Canada; Clare Karten, Leukemia and Lymphoma Society, White Plains, NY; Douglas K. Hawley, Onc Heme Care, Cincinnati, OH; Nicole M. Kuderer, Duke University Comprehensive Cancer Center, Durham, NC; Kieren A. Marr, Johns Hopkins School of Medicine, Baltimore, MD; Kenneth V.I. Rolston, University of Texas MD Anderson Cancer Center, Houston, TX; and Scott D. Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA.

1. Corresponding author: Jerome Seidenfeld, PhD, American Society of Clinical Oncology, 2318 Mill Rd, Suite 800, Alexandria, VA 22314; e-mail: jerry.seidenfeld@asco.org.

© 2013 by American Society of Clinical OncologyAbstract

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.

Footnotes

• See accompanying article in J Oncol Pract doi: 10.1200/JOP.2012.000815
• American Society of Clinical Oncology Clinical Practice Guideline Committee approved: September 5, 2012.
• Editor's note: This represents a brief summary overview of the complete American Society of Clinical Oncology Clinical Practice Guideline and provides the recommendations with brief discussions of the relevant literature for each. The complete guideline, which includes comprehensive discussions of the literature, methodology information, and all cited references, plus Data Supplements with evidence tables the committee used to formulate these recommendations and a list of all abbreviations used in the text, tables, and figures are available at www.asco.org/guidelines/outpatientfn.
• Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this articl