Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients
Abstract
Background
Fever occurring in a neutropenic patient remains a common life‐threatening complication of cancer chemotherapy. The common practice is to admit the patient to hospital and treat empirically with intravenous broad‐spectrum antibiotics. Oral therapy could be an alternative approach for selected patients.
Objectives
To compare the efficacy of oral antibiotics versus intravenous (IV) antibiotic therapy in febrile neutropenic cancer patients.
Search methods
The Cochrane Central Register of Controlled Trials (CENTRAL), (September 2007) on the Cochrane Library (Issue 2, 2007), MEDLINE (1966 to 2007), EMBASE (1980 to 2007) and LILACS (1982 to 2007). We searched several databases for ongoing trials. We checked the conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) 1995 to 2007 and all references of included studies and major reviews were scanned.
Selection criteria
RCTs comparing oral antibiotic/s to intravenous antibiotic/s for the treatment of neutropenic cancer patients with fever. The comparison between the two could be started initially (initial oral), or following an initial course of intravenous antibiotic treatment (sequential).
Data collection and analysis
Two reviewer authors independently assessed trial eligibility, methodological quality and extracted data. Data concerning mortality, treatment failures and adverse events were extracted from included studies assuming an "intention‐to‐treat" basis for the outcome measures whenever possible. Relative risks (RR) with 95% CIs (CI) for dichotomous data were estimated.
Main results
Eighteen trials were included in the analyses. The mortality rate was similar comparing oral to intravenous antibiotic treatment (RR 0.95, 95% CI 0.54 to 1.68, 9 trials, 1392 patients, median mortality 0, range 0 to 8.8%). Treatment failure rates were also similar (RR 0.95, 95% CI 0.85 to 1.07, all trials). No significant heterogeneity was shown for all comparisons but adverse events. This effect was stable in a wide range of patients. Quinolones alone or combined with another antibiotics were used with comparable results. Adverse reactions, mostly gastrointestinal were more common with oral antibiotics.
Authors' conclusions
Based on the present data, oral treatment is an acceptable alternative to intravenous antibiotic treatment in febrile neutropenic cancer patients (excluding patients with acute leukaemia) who are haemodynamically stable, without organ failure, not having pneumonia, infection of a central line or a severe soft‐tissue infection. The wide CI for mortality allows the present use of oral treatment in groups of patients with an expected low risk for mortality, and further research should be aimed at clarifying the definition of low risk patients.
PICOs
Plain language summary
Oral antibiotics are an acceptable alternative to intravenous antibiotics for treating febrile neutropenia in cancer patients at low risk for complications
Neutropenia (low white blood count) is a complication of cancer chemotherapy exposing patients to life‐threatening infections. Current practice for neutropenic patients with fever is hospital admission and treatment with intravenous antibiotics. Febrile neutropenia encompasses a spectrum of disease severity and low risk patients may be treated less aggressively. This review of randomised controlled trials (RCTs) showed comparable death and failure rates for oral and intravenous antibiotics for low risk patients, with solid tumours, chronic leukaemia or lymphoma, independent of age, source of infection and severity of the neutropenia.
