When can a patient with febrile neutropenia be discharged?

From the Guidelines

A patient with febrile neutropenia can be discharged when they meet specific criteria, including being afebrile for at least 24 hours, having a trending upward absolute neutrophil count (ANC) of >500 cells/mm³, and demonstrating clinical stability, as supported by the most recent guidelines 1.

Discharge Criteria

To determine the appropriate time for discharge, the following factors should be considered:

• The patient should be afebrile for at least 24 hours after stopping intravenous antibiotics and fluconazole, as indicated in the guidelines 1.
• The ANC should be trending upward and ideally >500 cells/mm³, which is a critical threshold for reducing the risk of infection, as noted in the study 1.
• The patient should demonstrate hemodynamic stability, have adequate oral intake, and be able to manage any ongoing toxicity as an outpatient, highlighting the importance of overall clinical stability 1.
• Platelet counts should be >20,000/mm³, independent of transfusion, to minimize the risk of bleeding complications, as recommended in the guidelines 1.

Management and Follow-Up

It is essential to ensure that patients can safely perform activities of daily living and that it is feasible to manage any ongoing toxicity as an outpatient, with close follow-up and coordination of care, as emphasized in the study 1.

• Patients may require hydration and/or transfusion support after discharge, and close follow-up is necessary to address any potential complications, as noted in the guidelines 1.
• Patients should remain in close proximity to the treatment center for 30 days after infusion, especially if they experience extensive cytopenias, due to the higher risk of post-IL-2 infection, as recommended in the study 1.

Rationale

The rationale for these criteria is that neutropenic patients remain vulnerable to infection until neutrophil recovery occurs, but those showing clinical improvement with resolving neutropenia have a significantly reduced risk of serious infectious complications, as supported by the guidelines 1. By prioritizing the most recent and highest-quality study 1, we can ensure that patients with febrile neutropenia receive evidence-based care that minimizes their risk of morbidity, mortality, and improves their quality of life.

From the Research

Discharge Criteria for Febrile Neutropenia

• Patients with febrile neutropenia can be discharged after a minimum of 48 hours with no further antibiotic therapy once they have been afebrile for 24 hours with negative blood cultures from initial presentation, regardless of their neutrophil count 2.
• Discharge is possible when the patient is afebrile, has negative blood cultures, appears well, and usually has some evidence of bone marrow recovery 3.
• The Multinational Association of Supportive Care in Cancer (MASCC) risk-index can be used to identify low-risk patients who can be discharged 24 hours after fever defervescence with subsequent oral antibiotic therapy 4.
• Selected febrile neutropenic children with cancer can be safely discharged after short courses of intravenous empirical antibiotic treatment, regardless of absolute neutrophil count (ANC) or evidence of bone marrow recovery, as long as they are afebrile for at least 24 hours and have been treated for a minimum of 72 hours 5.

Patient Selection for Early Discharge

• Patients with acute lymphoblastic leukemia and those with an ANC of ≤100 cells/mm(3) are more likely to be readmitted for fever 2.
• A declining ANC and advanced malignancy are risk factors in predicting recurrence of fever following discharge 3.
• Patients with acute myeloid leukemia and ANC <100 at discharge are more likely to be readmitted 6.

Outcomes of Early Discharge

• Early discharge produces acceptable rates of readmission and subsequent infection, and does not lead to increased morbidity and mortality 2.
• The risk of readmission and infectious complications is low in patients discharged before ANC recovery 6.
• Only a small percentage of patients discharged early require readmission to the intensive care unit or have positive blood cultures upon readmission 2, 6.