Treating Febrile Neutropenia From the Community Pharmacy

Cancer treatment is more closely involving community and specialty pharmacies, as many patients are being treated with oral, subcutaneous, and intravenous (IV) agents in the comfort of their own homes.

This is a good thing, as it curbs costs associated with hospital-based treatment, allows patients to continue functioning in familiar environments, and reduces nosocomial infection rates.

One area where cancer treatment has become more community-based is chemotherapy-induced febrile neutropenia (FN). A recent article published in the American Journal of Health-Systems Pharmacy underscored this change by thoroughly covering outpatient management of FN, bringing community pharmacists up to speed on the current standard of care.

FN development in cancer patients traditionally led to hospitalization and IV antibiotics, due to potentially life-threatening complications. Today, however, certain identifiable patients can be safely treated as outpatients.

Risk factors for FN include very low or rapidly decreasing neutrophil counts, neutropenia that persists for 7 days or more, hematologic malignancy, more intense chemotherapy, older age, and pre-existing infections.

The article authors described 2 tools used to identify patients at low risk for FN complications and discussed their strengths and limitations.

Those with prolonged, pronounced FN always require hospitalization and IV therapy, as do patients with significant comorbidities.

Once clinicians determine that patients are low-risk for FN, outpatient treatment with oral antibiotics is possible. In fact, hospitalized patients often receive oral antibiotics as alternatives to IV drugs, as well.

Most clinical guidelines recommend an oral fluoroquinolone, such as ciprofloxacin, in combination with oral amoxicillin-clavulanate—a regimen that requires multiple daily doses. Ciprofloxacin’s most common adverse events include diarrhea, nausea, and vomiting, which can be severe enough to cause patients to discontinue therapy.

Other fluoroquinolones have been assessed successfully in clinical trials, but guidelines still recommend the ciprofloxacin/amoxicillin-clavulanate regimen as first-line treatment.

Guidelines are consistent in several recommendations. For instance, clinicians need to draw at least 2 blood cultures from different sites (e.g. peripheral and central) before starting antibiotics. They also must acknowledge that logistics can make or break outpatient treatment and affect safety.

Other important considerations for pharmacists include the patient’s ability to physically reach a medical facility within 1 hour, access to a home caregiver, and availability of transportation.

“As part of the multidisciplinary team, a pharmacist can assist with the risk assessment of an individual patient with FN to determine whether outpatient treatment is appropriate,” the authors wrote. “…

Once the episode of FN has resolved, the pharmacist can work with the multidisciplinary team to determine whether immunizations, prophylactic antimicrobial therapy, or filgrastim use is warranted during the next cycle of cancer therapy.”