What are the ASCO/IDSA guidelines for the risk assessment of neutropenic cancer patients?

Updated: Sep 16, 2018
  • Author: Alexandre Chan, PharmD, MPH, FCCP, BCPS (AQ-ID), BCOP; more...
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Answer

Answer

Risk stratification is required to determine the management of patients with fever and neutropenia, including the route of antibiotic therapy (oral vs. IV), its duration, and the choice of inpatient or outpatient care. Widely accepted indications of high risk include either or both of the following:

  • Chemotherapy-related neutropenia that is expected to be prolonged (duration > 7 days) and profound (absolute neutrophil count [ANC] < 100 cells/μL
  • Significant  medical co-morbid conditions  (eg, hypotension, pneumonia, new-onset abdominal pain, neurologic changes)

Risk assessment recommendations are as follows:

  •   The Multinational Association for Supportive Care in Cancer (MASCC) scoring system or Talcott's rules can be used for a formal assessment of risk; a MASCC score < 21 indicates high risk
  • Clinical judgment should be used when selecting candidates for outpatient management. Patients with significant co-morbidity may not be candidates for outpatient treatment, even if their MASCC score is ≥ 21.
  • In patients with solid tumors who have undergone mild- to moderate-intensity chemotherapy, who appear to be clinically stable, and who are in close proximity to an appropriate medical facility that can provide 24-hour access, the Clinical Index of Stable Febrile Neutropenia (CISNE) may be used as an additional tool to determine the risk of major complications.
  • Patients infected with fluoroquinolone-resistant, gram-negative pathogens that are also coresistant to β-lactams/cephalosporins should receive inpatient treatment with a carbapenem-based regimen that likely requires multiple doses per day.

  • Patients colonized with, or suspected of having methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE) , or Stenotrophomonas maltophilia infection should be considered as candidates for inpatient management.

  • Patients undergoing HSCT or induction therapy for acute leukemia are unlikely to be appropriate candidates for outpatient therapy.

  • Patients whose degree of risk has not yet been determined to be high or low within 1 hour after triage should receive an initial IV dose of therapy while undergoing evaluation

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