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Outpatient Management of Febrile Neutropenia: Should We Change the Standard of Care?

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA

Correspondence: James A. Talcott, M.D., S.M., Center for Outcomes Research, Massachusetts General Hospital, B75 230, 55 Fruit Street, Boston, Massachusetts 02114, USA. Telephone 617-724-5451; Fax: 617-724-5457; e-mail: talcott{at}dfci.harvard.edu

The syndrome of fever and neutropenia is an iatrogenic complication of cytotoxic therapy for cancer. Because febrile neutropenia is associated with serious infection, patients with the syndrome are treated emergently with broad-spectrum, high-dose antibiotics. Recently, a differentiated approach to febrile neutropenia has been explored, based on assessment of risk. Prediction rules to identify low-risk patients were developed, and outpatient management of low-risk patients has been explored. Based on pilot studies and early randomized trials, some have called for a new standard of outpatient care. This article describes the scientific rationale for the current standard of care for febrile neutropenia; reviews the risk assessment studies; discusses the issues of safety, quality of life, and shifting of economic burdens arising when outpatient care is substituted for inpatient care—a change in practice patterns sweeping through acute care medicine with little scrutiny; and critically reviews the published trials of outpatient treatment of febrile neutropenia.

Key Words. Fever • Neutropenia • Risk assessment • Practice guidelines • Outpatient care