الفهرس 
Implementation of clinical pathway for pediatric patients with low-risk febrile neutropenia at the national cancer institute
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Abstract
Outpatient Management of low-risk fever and neutropenia should be
implemented if close monitoring is accessible and patient compliance is
feasible. There are not enough studies assessing the tolerance, safety, and
efficacy of Amoxicillin/clavulanate plus ciprofloxacin, Levofloxacin, and
Moxifloxacin for the treatment of low-risk febrile neutropenia.
Objective:
In this study, we aimed to assess the safety and efficacy of implementing
a clinical pathway using oral antibiotics. We performed randomization
between using single-agent Levofloxacin versus
Augmentin/Ciprofloxacin regimen used in our institute.
Patients and methods:
This is a randomized prospective interventional 2-arm study of low-risk
febrile neutropenia patients presenting to the emergency department at the
National Cancer Institute, Cairo University starting from December 2021
to October 2022.
Patients were randomized to double-agent ciprofloxacin and amoxicillinclavulanate
compared to a single-agent Levofloxacin. Follow-up of the
outpatient cases on Day 1, Day 3, and Day 7.
Primary outcomes included: (1) Safe marrow recovery (2) Improvement
of fever in all eligible patients. (3) Detecting drug-related side effects
encountered in both arms of the study.
Results:
Two hundred episodes of low-risk febrile neutropenia were enrolled in
our trial, one hundred in each arm.
On day one, all patients diagnosed as low risk started oral antibiotics and
were Instructed about follow-up, compliance, social situation, and
alarming signs.
On day three, 98% of patients in the levofloxacin arm were afebrile for 24
hours, and 61% in the same arm showed bone marrow recovery.
Compared, 83% of afebrile patients in the double agent’s arm and 44 % in
the same arm showed recovery counts. One patient was admitted to the
ward due to pneumonia on day three. Statistical significance was in favor
vi
of levofloxacin both in fever defervescence and count recovery with a Pvalue
that equals <0.001 and 0.016 respectively.
At day five in the levofloxacin receiving arm, 100 patients were afebrile
compared to 98 in the double agents receiving arm. One patient was
admitted to the ward due to persistent fever in the double agents receiving
arm.
At day seven, all the study patients were afebrile, had recovery counts,
and stopped antibiotics. The recovering counts showed statistical
significance in favor of levofloxacin at day 7 with p-value <0.001. This
indicates the success of our pathway in detecting and managing low-risk
febrile neutropenic patients.
Regarding drug-related side effects, 6% of patients in the levofloxacin
receiving arm complained of drug-related dyspepsia. Eight percent of the
double agent group complained of drug-related diarrhea, and 11%
complained of the bad taste of ciprofloxacin. Both were of statistical
significance with a p-value of <0.001 for the bad taste and p- value 0.003
for the diarrhea.
Conclusion:
Implementing a clinical pathway for children with low-risk febrile
neutropenia helps in the appropriate management of these patients and
decreases hospital costs and the incidence of nosocomial infections.
Levofloxacin has better efficacy and can be administered safely in
children with low-risk FN.
Close follow-up for long-term side effects and monitoring of possible
emerging bacterial resistance is warranted following the use of
Levofloxacin, especially in settings with a high incidence of MDR
bacterial infection.