a
Clinical judgment should be used when selecting candidates for outpatient management.
(Strong Recommendation; CB-L)
b
e MASCC index or Talcott's rules are recommended tools for identifying patients who
may be candidates for outpatient management (Table 2, Table 3, respectively). (Moderate
Recommendation; EB-I)
c
In the setting of a high prevalence of ESBL-producing Gram-negative bacilli or
fluoroquinolone resistance hospital admission and initial empirical anti-bacterial treatment
with an anti-pseudomonal carbapenem is recommended. In the setting of a high prevalence of
MRSA and VRE and concern for pneumonia or central line-associated bloodstream infection
hospital admission and targeted therapy is recommended. Patients undergoing hematopoietic
stem cell transplantation (HSCT) or induction therapy for acute leukemia are unlikely to be
appropriate candidates for outpatient therapy.
d
Patients with febrile neutropenia who are eligible for discharge and outpatient management
must also meet the following psychosocial and logistic requirements:
• Residence ≤1 hour or ≤30 miles (48 km) from clinic or hospital
• Patient's primary care physician or oncologist agrees to outpatient management
• Able to comply with logistic requirements, including frequent clinic visits
• Family member or caregiver at home 24 hours a day
• Access to a telephone and transportation 24 hours a day
• No history of noncompliance with treatment protocols
• e following additional measures are recommended:
• Frequent evaluation for ≥3 days in clinic or at home
• Daily or frequent telephone contact to verify (by home thermometry) that fever resolves
• Monitoring of ANC and platelet count for myeloid reconstitution
• Frequent return visits to clinic. (Moderate Recommendation; CB-L)
e
Low-risk outpatients with febrile neutropenia who do not defervesce aer two to three days
of an initial empirical broad-spectrum antibiotic regimen should be re-evaluated to detect and
treat a new or progressing anatomic site of infection and be considered for hospitalization.
Patients should also be evaluated for admission to the hospital if any of the following occur:
fever recurrence aer a period of defervescence, new signs or symptoms of infection, use of oral
medications is no longer possible or tolerable, change in the empirical regimen or an additional
antimicrobial drug becomes necessary, or microbiologic tests identify species not susceptible
to the initial regimen. (Moderate Recommendation; CB-L)
f
In patients with fever and neutropenia who are appropriate candidates for outpatient
management, the first dose of empirical therapy should be administered in the clinic,
emergency room, or hospital department aer fever has been documented and pretreatment
blood samples drawn. (Moderate Recommendation; CB-L)
g
For patients with FN who are undergoing outpatient antibiotic treatment, oral empirical
therapy with a fluoroquinolone (ciprofloxacin or levofloxacin) plus amoxicillin/clavulanate
(or plus clindamycin for those with a penicillin allerg y) is recommended. (Moderate
Recommendation; CB-I)
Figure 2. Identification of Candidates for Outpatient
Management—Footnotes
