Clinical Scenario Continued: Your febrile neutropenic patient has been started on antibiotics with blood cultures sent and you are pending a return page from her oncologist. The patient starts asking you if you could discharge her home because she feels a lot better and does not want to be in the hospital. Her vital signs have improved and she is no longer tachycardic or febrile, she tolerated PO in the department and ambulated. Your lab work and chest x-ray have been unremarkable other than neutropenia.
Question 1: Are neutropenic fever patients ever considered low risk?
Under the IDSA guidelines, most experts consider high risk patients to be those who have anticipated prolonged and profound neutropenia (>7 days with ANC≤100mm3 after cytotoxic chemotherapy), and/or have comorbid medical conditions like hypotension, pneumonia, neurological changes, or new abdominal pain. Low risk patients are those whose neutropenic periods are anticipated to be brief (≤7 days) with few or no co-morbidities.
Question 2: Should you discharge a low-risk neutropenic fever patient home from the ED with oral antibiotics?
There are validated risk-stratification tools that help identify low-risk febrile neutropenic patients that could be sent home on oral antibiotics, used in the clinic and inpatient settings, two of which are the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE). You can find these calculators here:
There has been a recent retrospective study on these two tools on inpatients by Coyne et al. 2017: http://www.annemergmed.com/article/S0196-0644(16)31352-X/abstract
The CINSE was found to be highly specific in identifying low-risk patients (98.3% specific with 95% CI 89.7-99.9%) while MASCC was found to be much less specific (54.2% with 95% CI 40.8-67.1%). However, this a retrospective study on inpatients and whether this can be extrapolated to discharged patients on oral antibiotics from the ED is still a question. Prospective data is needed.
You can find the EM:RAP commentary on this study here: http://www.annemergmed.com/article/S0196-0644(17)30416-X/pdf
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