Skip to main content

Advertisement

SpringerLink
Log in

Clinical practice patterns of managing low-risk adult febrile neutropenia during cancer chemotherapy in the USA

  • Original Article
  • Published:
Supportive Care in Cancer Aims and scope Submit manuscript

Abstract

Purpose

The purpose of the study was to determine oncologists’ current practice patterns for antibiotic management of low-risk fever and neutropenia (FN) after chemotherapy.

Materials and methods

A self-administered survey was developed to query management practices for low-risk FN patients and sent to 3,600 randomly selected American Society of Clinical Oncology physician members; hypothetical case scenarios were included to assess factors influencing decisions about outpatient treatment.

Results

Of 3,560 actively practicing oncologists, 1,207 replied (34%). Outpatient antibiotics are used by 82% for selected low-risk FN patients (27% used in them >65% of their patients). Oral levofloxacin (50%), ciprofloxacin (36%), and ciprofloxacin plus amoxicillin/clavulanate (35%) are common outpatient regimens. Fluoroquinolone prophylaxis is used by 45% of oncologists, in a subset of afebrile patients at low risk for FN; growth factors are used adjunctively by 48% for treating low-risk FN. Factors associated with choosing outpatient treatment were: frequency of use in oncologists’ own practices, absence of hematologic malignancy, lower patient age, no infiltrate on X-ray, no prior serious infection, shorter expected FN duration, lower creatinine levels, and shorter distance of patient’s residence from the hospital.

Conclusions

US oncologists, who responded are willing to prescribe outpatient oral antibiotic treatment for low-risk FN, although practices vary considerably and are based on favorable clinical factors. However, practices are often employed that are not recommended for low-risk patients by current guidelines, including fluoroquinolone prophylaxis, adjunctive and/or prophylactic growth factors, and use of levofloxacin for empiric therapy. Educational efforts are needed to better guide cost-effective and supportive care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Asch DA, Jedrziewski MK, Christakis NA (1997) Response rates to mail surveys published in medical journals. J Clin Epidemiol 50(10):1129–1136

    Article  PubMed  CAS  Google Scholar 

  2. Berger P, Pascal L, Sartor C, Delorme J, Monge P, Ragon CP, Charbit M, Sambuc R, Drancourt M (2004) Generalized additive model demonstrates fluoroquinolone use/resistance relationships for Staphylococcus aureus. Eur J Epidemiol 19(5):453–460

    Article  PubMed  CAS  Google Scholar 

  3. Bodey GP, Buckley M, Sathe YS, Freireich EJ (1966) Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann Intern Med 64(2):328–340

    PubMed  CAS  Google Scholar 

  4. Cordonnier C, Magnier C, Leverger G, Ghanassia JP, Herbrech R, Clioh (2004) Results of a survey on practices in onco-hematology in France in 2001. Presse Med 33(5):324–326

    Article  PubMed  Google Scholar 

  5. Cullen M, Steven N, Billingham L et al (2005) Antibacterial prophylaxis after chemotherapy for solid tumors and lymphomas. N Engl J Med 353(10):988–998

    Article  PubMed  CAS  Google Scholar 

  6. Cummings SM, Savitz LA, Konrad TR (2001) Reported response rates to mailed physician questionnaires. Health Serv Res 35(6):1347–1355

    PubMed  CAS  Google Scholar 

  7. Dillman DA, Dillman DA (2000) Mail and internet surveys: the tailored design method. Wiley, New York

    Google Scholar 

  8. Elting LS, Bodey GP, Keefe BH (1992) Septicemia and shock syndrome due to viridans streptococci: a case–control study of predisposing factors. Clin Infect Dis 14(6):1201–1207

    PubMed  CAS  Google Scholar 

  9. Elting LS, Rubenstein EB, Rolston KV, Bodey GP (1997) Outcomes of bacteremia in patients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis 25(2):247–259

    Article  PubMed  CAS  Google Scholar 

  10. Escalante CP, Weiser MA, Manzullo E et al (2004) Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients. Support Care Cancer 12(9):657–662

    PubMed  Google Scholar 

  11. Freifeld A, Baden LR, Brown AE et al (2006) National Comprehensive Cancer Network clinical practice guidelines in oncology: fever and neutropenia. NCCN, Jenkintown, PA

    Google Scholar 

  12. Freifeld A, Marchigiani D, Walsh T (1999) A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 341(5):305–311

    Article  PubMed  CAS  Google Scholar 

  13. Freifeld A, Sepkowitz K (2006) The conundrum of fluoroquinolone prophylaxis. Nat Clin Pract Oncol 3(10):524–525

    Article  PubMed  Google Scholar 

  14. Freifeld AG, Sepkowitz KA, Martino P, Steven N, Billingham L, Cullen M, Baden LR (2006) Antibacterial prophylaxis in patients with cancer and neutropenia. N Engl J Med 354(1):90–94; author reply 90–94

    Article  PubMed  Google Scholar 

  15. Garcia-Carbonero R, Mayordomo JI, Tornamira MV et al (2001) Granulocyte colony-stimulating factor in the treatment of high-risk febrile neutropenia: a multicenter randomized trial. J Natl Cancer Inst 93(1):31–38

    Article  PubMed  CAS  Google Scholar 

  16. Gasink LB, Fishman NO, Weiner MG, Nachamkin I, Bilker WB, Lautenbach E (2006) Fluoroquinolone-resistant Pseudomonas aeruginosa: assessment of risk factors and clinical impact. Am J Med 119(6):526.e19–526.e25

    Article  Google Scholar 

  17. Hughes WT, Armstrong D, Bodey GP et al (2002) Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 34(6):730–751

    Article  PubMed  Google Scholar 

  18. Innes H, Billingham L, Gaunt C, Steven N, Marshall E (2005) Management of febrile neutropenia in the United Kingdom: time for a national trial? Br J Cancer 93(12):1324–1328

    Article  PubMed  CAS  Google Scholar 

  19. Innes HE, Smith DB, O’Reilly SM, Clark PI, Kelly V, Marshall E (2003) Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study. Br J Cancer 89(1):43–49

    Article  PubMed  CAS  Google Scholar 

  20. Kaye KS, Kanafani ZA, Dodds AE, Engemann JJ, Weber SG, Carmeli Y (2006) Differential effects of levofloxacin and ciprofloxacin on the risk for isolation of quinolone-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother 50(6):2192–2196

    Article  PubMed  CAS  Google Scholar 

  21. Kern WV (2006) Risk assessment and treatment of low-risk patients with febrile neutropenia. Clin Infect Dis 42(4):533–540

    Article  PubMed  Google Scholar 

  22. Klastersky J (2004) Management of fever in neutropenic patients with different risks of complications. Clin Infect Dis 39(Suppl 1):S32–S37

    Article  PubMed  Google Scholar 

  23. Klastersky J, Paesmans M, Georgala A, Muanza F, Plehiers B, Dubreucq L, Lalami Y, Aoun M, Barette M (2006) Outpatient oral antibiotics for febrile neutropenic cancer patients using a score predictive for complications. J Clin Oncol 24(25):4129–4134

    Article  PubMed  CAS  Google Scholar 

  24. Klastersky J, Paesmans M, Rubenstein EB (2000) The multinational association for supportive care in cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol 18(16):3038–3051

    PubMed  CAS  Google Scholar 

  25. Kline RM, Baorto EP (2005) Treatment of pediatric febrile neutropenia in the era of vancomycin-resistant microbes. Pediatr Blood Cancer 44(3):207–214

    Article  PubMed  Google Scholar 

  26. Kuderer NM, Dale DC, Crawford J, Cosler LE, Lyman GH (2006) Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer 106(10):2258–2266

    Article  PubMed  Google Scholar 

  27. MacDougall C, Powell JP, Johnson CK, Edmond MB, Polk RE (2005) Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals. Clin Infect Dis 41(4):435–440

    Article  PubMed  CAS  Google Scholar 

  28. Mayordomo JI, Rivera F, Diaz-Puente MT, Lianes P, Colomer R, Lopez-Brea M, Lopez E, Paz-Ares L, Hitt R, Garcia-Ribas I (1995) Improving treatment of chemotherapy-induced neutropenic fever by administration of colony-stimulating factors. J Natl Cancer Inst 87(11):803–808

    Article  PubMed  CAS  Google Scholar 

  29. Morris CJ, Cantrill JA, Weiss MC (2001) GP survey response rate: a miscellany of influencing factors. Fam Pract 18(4):454–456

    Article  PubMed  CAS  Google Scholar 

  30. Paesmans M (2000) Risk factors assessment in fabrile neutropenia. Int J Antimicrob Agents 16(2):107–111

    Article  PubMed  CAS  Google Scholar 

  31. Pizzo PA (1993) Management of fever in patients with cancer and treatment-induced neutropenia. N Engl J Med 328(18):1323–1332

    Article  PubMed  CAS  Google Scholar 

  32. Ravaud A, Chevreau C, Cany L (1998) Granulocyte-macrophage colony-stimulating factor in patients with neutropenic fever is potent after low-risk but not after high-risk neutropenic chemotherapy regimens: results of a randomized phase III trial. J Clin Oncol 16(9):2930–2936

    PubMed  CAS  Google Scholar 

  33. Rolston KV, Manzullo EF, Elting LS, Frisbee-Hume SE, McMahon L, Theriault RL, Patel S, Benjamin RS (2006) Once daily, oral, outpatient quinolone monotherapy for low-risk cancer patients with fever and neutropenia: a pilot study of 40 patients based on validated risk-prediction rules. Cancer 106(11):2489–2494

    Article  PubMed  CAS  Google Scholar 

  34. Rubin M, Hathorn JW, Pizzo PA (1988) Controversies in the management of febrile neutropenic cancer patients. Cancer Invest 6(2):167–184

    Article  PubMed  CAS  Google Scholar 

  35. Santolaya ME, Alvarez AM, Aviles CL et al (2004) Early hospital discharge followed by outpatient management versus continued hospitalization of children with cancer, fever, and neutropenia at low risk for invasive bacterial infection. J Clin Oncol 22(18):3784–3789

    Article  PubMed  Google Scholar 

  36. Smith TJ, Khatcheressian J, Lyman GH et al (2006) Update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 24(19):3187–3205

    Article  PubMed  CAS  Google Scholar 

  37. Sung L, Feldman BM, Schwamborn G et al (2004) Inpatient versus outpatient management of low-risk pediatric febrile neutropenia: measuring parents’ and healthcare professionals’ preferences. J Clin Oncol 22(19):3922–3929

    Article  PubMed  Google Scholar 

  38. Talcott JA, Finberg R, Mayer RJ, Goldman L (1988) The medical course of cancer patients with fever and neutropenia. Clinical identification of a low-risk subgroup at presentation. Arch Intern Med 148(12):2561–2568

    Article  PubMed  CAS  Google Scholar 

  39. Talcott JA, Siegel RD, Finberg R, Goldman L (1992) Risk assessment in cancer patients with fever and neutropenia: a prospective, two-center validation of a prediction rule. J Clin Oncol 10(2):316–322

    PubMed  CAS  Google Scholar 

  40. Tamura K (2005) Clinical guidelines for the management of neutropenic patients with unexplained fever in Japan: validation by the Japan Febrile Neutropenia Study Group. Int J Antimicrob Agents 26(Suppl 2):S123–S127 discussion S133–S140

    Article  PubMed  CAS  Google Scholar 

  41. Vellenga E, Uyl-de Groot CA, de Wit R et al (1996) Randomized placebo-controlled trial of granulocyte-macrophage colony-stimulating factor in patients with chemotherapy-related febrile neutropenia. J Clin Oncol 14(2):619–627

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We would like to acknowledge the valuable contributions of JoCarol McNabb, Pharm.D., MPA, to the conception and implementation of the study, during her former association as Assistant Professor with Department of Pharmacy Practice at University of Nebraska Medical Center. This study was supported by a grant from Ortho-McNeill Pharmaceuticals.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA

    Alison Freifeld

  2. Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA

    Jayashri Sankaranarayanan

  3. College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA

    Fred Ullrich

  4. Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA

    Junfeng Sun

  5. Immunocompromised Host Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE, 68198-5400, USA

    Alison Freifeld

Authors
  1. Alison Freifeld
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jayashri Sankaranarayanan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Fred Ullrich
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Junfeng Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alison Freifeld.

Appendix

Appendix

Rights and permissions

Reprints and permissions

About this article

Cite this article

Freifeld, A., Sankaranarayanan, J., Ullrich, F. et al. Clinical practice patterns of managing low-risk adult febrile neutropenia during cancer chemotherapy in the USA. Support Care Cancer 16, 181–191 (2008). https://doi.org/10.1007/s00520-007-0308-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00520-007-0308-x

Keywords

Search

Navigation