Malik I A, Khan W A, Karim M, Aziz Z, Khan M A
Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
Am J Med. 1995 Mar;98(3):224-31. doi: 10.1016/s0002-9343(99)80367-2.
We recently demonstrated the efficacy of single-agent oral ofloxacin in the management of hospitalized neutropenic febrile patients. Ofloxacin was particularly effective in patients with short duration of neutropenia and fever of undetermined origin. These results prompted us to study the feasibility of outpatient management of neutropenic febrile patients who are otherwise at low risk of morbidity and mortality.
This multi-institutional, prospective, randomized trial included 182 low-risk neutropenic febrile episodes. After an initial work-up for fever, patients were randomized to receive oral ofloxacin 400 mg immediately and twice daily thereafter in the hospital or as outpatients. Close monitoring and follow-up were carried out in all patients. Those who failed to respond and remained febrile were given parenteral antibiotics. Nonresponding outpatients were admitted to the hospital for parenteral therapy.
One hundred sixty-nine episodes were evaluable. The hospital and outpatient treatment groups had comparable clinical characteristics. Pyrexias of undetermined origin (PUO) comprised 69% of episodes managed in hospital and 73% of episodes treated outside. The success rate with PUO was similar with inpatient and outpatient management. Patients with clinical and microbiologic infections fared less well than those with PUO. Overall, 78% of inpatient and 77% of outpatient fevers resolved with no modification of the initial treatment. Twenty-one percent of patients originally assigned to outside management required hospitalization. Mortality was 2% among inpatients and 4% among outpatients. One early death in a nonhospitalized patient underscores the need for close monitoring and surveillance in these cases.
Outpatient management of low-risk neutropenic febrile patients with ofloxacin is as effective as inpatient management with the same agent. This approach should be limited to the subset of patients with low-risk factors who are not otherwise on quinolone prophylaxis.
我们最近证明了单剂口服氧氟沙星在治疗住院中性粒细胞减少发热患者中的疗效。氧氟沙星在中性粒细胞减少持续时间短且病因不明发热的患者中特别有效。这些结果促使我们研究对发病和死亡风险较低的中性粒细胞减少发热患者进行门诊治疗的可行性。
这项多机构、前瞻性、随机试验纳入了182例低风险中性粒细胞减少发热发作。在对发热进行初步检查后，患者被随机分为两组，一组在医院或门诊立即口服400毫克氧氟沙星，之后每日两次。对所有患者进行密切监测和随访。那些无反应且持续发热的患者给予胃肠外抗生素治疗。无反应的门诊患者入院接受胃肠外治疗。
169例发作可进行评估。住院治疗组和门诊治疗组具有可比的临床特征。不明原因发热（PUO）在住院治疗的发作中占69%，在门诊治疗的发作中占73%。住院和门诊治疗PUO的成功率相似。有临床和微生物感染的患者比PUO患者的情况要差。总体而言，78%的住院患者和77%的门诊患者发热消退，且未改变初始治疗。最初分配到门诊治疗的患者中有21%需要住院。住院患者死亡率为2%，门诊患者死亡率为4%。一名非住院患者早期死亡凸显了对这些病例进行密切监测和监督的必要性。
用氧氟沙星对低风险中性粒细胞减少发热患者进行门诊治疗与用同一药物进行住院治疗一样有效。这种方法应仅限于那些没有其他喹诺酮预防措施且风险因素较低的患者亚组。
