The American
Society of Clinical Oncology published their clinical practice guideline
for antimicrobial prophylaxis and outpatient management of fever and
neutropenia in adults treated for malignancy. The guidelines were based on 43
studies.
These were the 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.
Even though the principles
behind these guidelines are similar to the ones used for the treatment of individuals
who developed neutropenia after exposure to ionized radiation, caution should be used in implementing these guidelines for those who
were irradiated. There is a risk in using antimicrobials effective against
anaerobic bacteria (amoxicillin/clavulanate or clindamycin) in individuals
exposed to ionizing radiation as studies in rodents illustrated the developmentof early sepsis in those treated with such agents.
Neutropenia
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