Written by Clay Smith
It appears that there is no difference in treatment failure or mortality when low-risk febrile neutropenia patients are treated at home vs inpatient. But be very cautious about this.
Why does this matter?
Both the CISNE and MASCC scores have been retrospectively and prospectively derived and validated to determine which patients with fever and neutropenia are low risk and may avoid hospitalization. They have numerous caveats, and no RCTs have included them yet. So, they don’t show up in this meta-analysis. Despite this, ASCO and the IDSA have issued joint guidelines on risk stratification and outpatient treatment for select patients that combine both MASCC and CISNE scores into the algorithm. This is a review of several other RCTs in regard to outpatient management of febrile neutropenia.
Just schedule an appointment in the septic shock clinic…
Among patients with febrile neutropenia, 50-60% don’t have a life-threatening complication or fatal infection. This was a meta-analysis of 10 RCTs (6 adult/4 pediatric) comparing inpatient vs outpatient low-risk febrile neutropenia patients. “Low-risk” definitions were variable but usually meant patients would not: “a) need hospitalization, b) have focal or severe infection, c) have relapse of the disease, and d) be receiving intensive chemotherapy.” Overall, there was no difference in treatment failure or mortality when select patients were treated as outpatients. Most patients were watched in the hospital for 1-3 days. So, just 2 of 10 studies were true outpatient treatment with immediate discharge of low-risk patients. None used the MASCC or CISNE criteria, and there are no validated low-risk criteria for children. Overall quality of evidence was low to moderate, and most trials were small with wide confidence intervals. Larger, better quality studies are needed.
Here is my take. ASCO and IDSA consider outpatient management of febrile neutropenia to be a viable option. But be careful - the MASCC and CISNE scores don’t consider everything - not even close! This is a tough decision, with numerous medical and psychosocial caveats and should only be made with the patient’s oncologist and shared decision making with the patient.
See the full Cochrane Review of this topic.
Outpatient Treatment for Low-Risk Febrile Neutropenia. Acad Emerg Med. 2019 Aug 17. doi: 10.1111/acem.13847. [Epub ahead of print]
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Reviewed by Thomas Davis