PILOT STUDY PROPOSAL FOR EARLY DISCHARGE OF LOW-RISK NEUTROPENIC PATIENTS RATIONALE: It is increasingly being recognised that not all neutropenic patients have the same risk of complications during episodes of febrile neutropenia. A group of low risk patients can be reliably identified and the intensity of their treatment safely reduced allowing early discharge with significant reductions in length of stay and cost (1). Importantly identifying low risk patients also highlights the high-risk group whose mortality rate is 15% allowing these patients to be managed aggressively from an earlier stage. Currently 5-10 patients with neutropenic sepsis are admitted to the RUH per month from a variety of sources (oncology outpatients, day unit, MAU, A+E). A retrospective look at 15 patients documented in the William Budd outlier book admitted with neutropenic sepsis between 1 st April and 26 th June 2008 showed they had an average bed stay of 5.6 days but that 7 of them might have been suitable for early discharge on oral antibiotics, thereby freeing up beds with significant cost savings. The MASCC index was first developed in 2000 by Klastersky et al (2) to identify low risk patients and has been prospectively validated in a multinational trial (3) with a positive predictive value of 91%, specificity of 68% and sensitivity of 71%. A trial of early discharge in 102 low risk patients at Clatterbridge (4) showed similar efficacy between the oral and iv antibiotic arms with resolution of fever with 1 st line antibiotics in 84.8 and 90% of patients respectively (p=0.55). Only 1 patient deteriorated significantly in the oral antibiotic group and this occurred in the initial 24 hr in-patient assessment period. 5 patients in the oral antibiotic arm required re-admission for 2 nd line iv antibiotics, with no deaths in either arm. Although the MASCC score was published after this trial began the authors retrospectively scored their patients using it and found >95% of their trial patients fitted this definition of low risk. Many centres both in the UK and abroad are now tailoring treatment of neutropenic sepsis rather than having a blanket approach and are using oral antibiotics 1 st line in low risk patients followed by early discharge at 24 hours for those patients who remain clinically stable. PROPOSAL: A 3 month pilot study introducing the MASCC index for stratifying risk of complications for all patients presenting with febrile neutropenia after chemotherapy. All low risk patients would then receive oral antibiotics (Augmentin + Ciprofloxacin) unless penicillin allergic, from time of admission. At 24 hours those patients fitting discharge criteria would be reviewed by an oncology or haematology SpR or consultant and discharged home on oral antibiotics for follow up in the oncology day unit 48 hours after discharge. The oncology/ haematology team would also be responsible for following up outstanding blood culture results. High risk patients would continue to receive iv antibiotics from the outset but we would envisage that anyone unable to be discharged home at 24 hours should then be prioritised for transfer to William Budd ward. REFERENCES 1
1) Vidal.L, Paul.M, Ben-Dor.I, Soares-Weiser.K, Leibovici.L. Oral versus intravenous antibiotic treatment for febrile neutropaenia in cancer patients. Cochrane Database of Systematic Reviews 2004 Issue 4. Art. No.: CD003992. DOI:10.1002/14651858.CD003992.pub2. 2) Klastersky.J. Management of Fever in Neutropenic Patients with Different Risks of Complications. CID 2004:39(suppl 1)S32-37 3) Klastersky.J et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. JCO 2000 18(16) 3038-3051 4) Innes.H, Smith.D, O Reilly.S, Clark, P, Kelly.V, Marshall.E. Oral antibiotics with early discharge compared with in-patient intravenous antibiotics in patients with cancer: a prospective randomised controlled single centre study. BJC 2003 89; 43-49. 2
Procedure for Treating Patients with Low Risk Febrile Neutropenia 1. Admit and use MASCC score to assign risk status. Patients who have a clearly evident source of infection such as an abscess, cellulitis, diarrhoea, pneumonia or line infection should be given antibiotics appropriate to this site. The admitting doctor should also check to see whether there have been any recent positive microbiology results which might influence choice of antibiotic. Patients who are penicillin allergic or who have received ciprofloxacin as prophylaxis should not be treated with the oral combination. 2. If there is any doubt as to the suitability of the patient for oral antibiotic therapy and early discharge they should be treated as severe with iv antibiotics. This can also be discussed with a haematologist, oncologist or microbiologist 3. Patients being treated with the expectation that they will be discharged home after 24 hrs should remain on MAU. 4. William Budd ward should be informed of all admissions for neutropenic sepsis immediately by faxing the MASCC score sheet to 5095. 5. All low risk patients (on oral antibiotics) are reviewed at approximately 24 hours by a haematology or oncology SpR/ consultant and are discharged home if appropriate, with a patient information sheet. High risk patients and those no longer suitable for early discharge should be transferred to William Budd as soon as possible. 6. The haematologist/ oncologist who reviews the patient is responsible for checking all culture results and arranging to see the patient at 48 hours on the oncology day unit (ideally in the morning). 7. Patients, in whom there has been any deterioration, should be re-admitted, preferably to William Budd ward. 3
Guidelines for the Treatment of Neutropenic Fever in Low Risk Patients This guideline is for low risk neutropenic patients (neutrophils <1x10 9 /L) who have a temperature 38 C. Repeated temperatures between 37.5 C and 38 C in a neutropenic patient may also be of clinical significance and should not be ignored. Severely shocked patients maybe hypothermic. Use the MASCC Index below to categorise patients into Severe or Non-severe. Acute leukaemia, Burkitts lymphoma, Allograft and Autograft patients are all treated as severe. Patients classed as severe should receive IV antibiotics as per the existing RUH protocol. MASCC Index: (Journal of Clinical Oncology 18: 3038-3051, 2000) Characteristic Score Age 60 years 0 < 60 years 2 Patient dehydrated, requiring fluids? No 3 Yes 0 Patient hypotensive? Systolic BP <90 0 Systolic BP 90 5 Does patient have COPD? Yes 0 (Chronic obstructive pulmonary disease) No 4 Does the patient have a solid tumour or no history Yes 4 of previous fungal infection? No 0 Does the patient have symptoms related to this None or mild symptoms 5 febrile neutropenic episode? Moderate symptoms 3 Severe symptoms 0 Was the patient already an inpatient? Already an inpatient 0 Admitted with this episode 3 If score 21 treat as non-severe. If in any doubt treat as severe. Criteria for oral antibiotic treatment: patients must fulfil all criteria MASCC score > 21 And no evidence of focal infection such as cellulitis, abscess, pneumonia, line infection And no diarrhoea or recent C.difficile infection And no allergy to penicillin or ciprofloxacin And no recent positive microbiology culture results suggesting that co-amoxiclav/ ciprofloxacin combination would be inappropriate And patient has not received prophylaxis with ciprofloxacin within last 28 days Patients not fitting above criteria should receive iv antibiotics as per the existing RUH protocol for neutropenic sepsis Oral Antibiotic treatment: Co-amoxiclav 625mg po tds + Ciprofloxacin 750mg po bd for 7 days Discharge criteria for non-severe patients: The discharge review must be carried out by a haematology or oncology SpR or consultant. Clinically stable and symptomatically improved, irrespective of neutrophil count Fever 37.9 o C on 3 occasions over a 24 hour period The patient must give a history of good compliance and must be willing to return to the ward at short notice in the event of antibiotic intolerance or clinical deterioration 4
Oral (Tablet) Antibiotics For Neutropenic Fever During Chemotherapy Patient Information Sheet You are going home with tablet antibiotics to treat your infection. We know this is sensible and safe practice, and of benefit to patients. However occasionally patients need to return to hospital for antibiotics through a drip. If you experience any of the following please phone William Budd ward on 01225 825093 or 01225 825092 immediately: o Vomiting e.g. Unable to drink a glass of water or vomiting more than 4 times in 24 hours o Rash or other concerns about allergy to antibiotic tablets o Diarrhoea e.g. more than 4 loose stools in 24 hours o Temperature more than 38 o C for an hour o Feeling much less well than when you left the ward. You will be seen on William Budd Day Unit approximately 48 hours after discharge. However please don t wait for this appointment if you have any of the above symptoms. Please phone for advice if you have any other concerns or worries In the event you are unwell and need to come back into hospital, we will do our best to admit you to William Budd ward. Please take this information with you if you attend another hospital/unit. The antibiotic policy is available for your doctor on the RUH intranet. Discharge information Antibiotics Co-amoxiclav 625mg x 3 a day Ciprofloxacin 750mg x 2 a day You will be seen on at To be taken for total 7 days (including hospital stay) 5