Mullen C A, Buchanan G R
Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas 75235-9063.
J Clin Oncol. 1990 Dec;8(12):1998-2004. doi: 10.1200/JCO.1990.8.12.1998.
Children with leukemia and solid tumors are often hospitalized for empiric broad-spectrum antibiotic therapy because of fever during periods of chemotherapy-induced neutropenia. Conventional practice dictates that parenteral antibiotics be continued until the patient is afebrile and has recovered from neutropenia, ie, until the absolute neutrophil count (ANC) exceeds 500 cells per cubic millimeter. However, the practice in our center has been to discontinue parenteral antibiotic therapy and discharge many such patients before resolution of neutropenia. Since the feasibility and safety of this approach has not been studied, we reviewed the records of 114 consecutive hospitalizations for fever and neutropenia in 61 patients during a 13-month period. Seventy-seven children (68%) were discharged to their homes while still neutropenic after they had been afebrile for 1 to 2 days on parenteral antibiotics, had negative blood cultures, appeared well, and usually had some evidence of bone marrow recovery. Five patients (4.4%) developed recurrent fever and required rehospitalization within 7 days of discharge. Only three of the 77 patients (3.9%) who were sent home with neutropenia had recurrent fever. Each had a brief and uneventful second hospitalization. Two of the 37 children discharged with an ANC over 500 cells per cubic millimeter required rehospitalization. A declining ANC and advanced malignancy were risk factors in predicting recurrence of fever following discharge. A rising monocyte count was a predictor of imminent recovery from neutropenia. These results suggest that "early" discharge of an afebrile yet still neutropenic patient is safe when the patient is in remission, has no evidence of serious infection, appears clinically stable, and has indications of bone marrow recovery. The conventional approach of routinely continuing the hospitalization until resolution of neutropenia may be unnecessary in such low-risk patients.
患有白血病和实体瘤的儿童在化疗引起的中性粒细胞减少期间常因发热而住院接受经验性广谱抗生素治疗。传统做法是持续使用肠外抗生素，直到患者退热且从中性粒细胞减少中恢复，即直到绝对中性粒细胞计数（ANC）超过每立方毫米500个细胞。然而，我们中心的做法是在中性粒细胞减少症尚未缓解之前就停止肠外抗生素治疗并让许多此类患者出院。由于这种方法的可行性和安全性尚未得到研究，我们回顾了61例患者在13个月期间因发热和中性粒细胞减少而连续114次住院的记录。77名儿童（68%）在接受肠外抗生素治疗1至2天退热、血培养阴性、状况良好且通常有骨髓恢复迹象后，虽仍处于中性粒细胞减少状态但已出院回家。5名患者（4.4%）出现复发性发热，在出院后7天内需要再次住院。77名中性粒细胞减少出院的患者中只有3名（3.9%）出现复发性发热。每人第二次住院时间短暂且情况平稳。37名ANC超过每立方毫米500个细胞出院的儿童中有2名需要再次住院。ANC下降和晚期恶性肿瘤是预测出院后发热复发的危险因素。单核细胞计数上升是中性粒细胞减少即将恢复的预测指标。这些结果表明，当患者处于缓解期、没有严重感染迹象、临床状况稳定且有骨髓恢复迹象时，发热但仍处于中性粒细胞减少状态的患者“早期”出院是安全的。对于此类低风险患者，常规持续住院直到中性粒细胞减少症缓解的做法可能没有必要。
