Outpatient management of febrile neutropenia in children with cancer

The objectives of this article are to review the studies that have examined the safety and feasibility of outpatient management for children with febrile neutropenia, and to provide recommendations as to which patient populations and treatment strategies are most appropriate for this approach. The outpatient strategies have included either complete outpatient management or employment of early discharge, with the latter methodology predominating in most published studies. Common criteria relied upon to identify children with febrile neutropenia at low risk of serious infections included evidence of hematopoietic recovery and/or an absolute monocyte count ≥100/mm3, and the absence of both comorbidity and culture positivity. A wide variety of different antibacterial regimens have been employed, with some trials investigating either early discontinuation of treatment or conversion to an oral administration strategy. Trials performed to date among this low risk population indicate a very low rate of readmission and/or complications. Some studies have also estimated substantial overall cost savings with this approach. However, many of these trials are significantly underpowered to detect the low rate of serious complications in the pediatric population with febrile neutropenia. At present, the available evidence indicates that a carefully chosen subpopulation of children with febrile neutropenia can be safely managed on an outpatient basis. Regardless of setting, current clinical guidelines for febrile neutropenia management indicate that all children with febrile neutropenia should be managed with appropriate antibacterial therapy until resolution of febrile neutropenia. Treatment with either an oral antibacterial regimen as initial therapy, or early discontinuation of antibacterial therapy in the outpatient setting should remain investigational at the present time.