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Feasibility of Withholding Antibiotics in Selected Febrile Neutropenic Cancer Patients

From the Division of Pediatric Oncology/Hematology, Beatrix Children's Hospital, Division of Hematology, Division of Medical Oncology, Division of Pulmonary Diseases, Department of Internal Medicine, Office for Medical Technology Assessment, Department of Medical Microbiology, University Hospital Groningen, the Netherlands

Address reprint requests to E.S.J.M. de Bont, MD, PhD, Division of Pediatric Oncology, Beatrix Children's Hospital, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands; e-mail: e.s.j.m.de.bont{at}bkk.umcg.nl

PURPOSE: To investigate the feasibility of withholding antibiotics and early discharge for patients with chemotherapy-induced neutropenia and fever at low risk of bacterial infection by a new risk assessment model.

PATIENTS AND METHODS: Outpatients with febrile neutropenia were allocated to one of three groups by a risk assessment model combining objective clinical parameters and plasma interleukin 8 level. Patients with signs of a bacterial infection and/or abnormal vital signs indicating sepsis were considered high risk. Based on their interleukin-8 level, remaining patients were allocated to low or medium risk for bacterial infection. Medium-risk and high-risk patients received standard antibiotic therapy, whereas low-risk patients did not receive antibiotics and were discharged from hospital after 12 hours of a febrile observation. End points were the feasibility of the treatment protocol.

RESULTS: Of 196 assessable episodes, 76 (39%) were classified as high risk, 84 (43%) as medium risk, and 36 (18%) as low risk. There were no treatment failures in the low-risk group (95% CI, 0% to 10%). Therefore, sensitivity of our risk assessment model was 100% (95% CI, 90% to 100%), the specificity, positive, and negative predictive values were 21%, 13%, and 100%, respectively. Median duration of hospitalization was 3 days in the low-risk group versus 7 days in the medium- and high-risk groups (P < .0001). The incremental costs of the experimental treatment protocol amounted to a saving of 471 (US $572) for every potentially low-risk patient.

CONCLUSION: This risk assessment model appears to identify febrile neutropenic patients at low risk for bacterial infection. Antibiotics can be withheld in well-defined neutropenic patients with fever.

Supported by a Grant from the Association of University Hospitals in the Netherlands.

Presented in part at the 39th Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, May 31-June 3, 2003.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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