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APNs in Outpatient Management of Febrile Neutropenia

APNs in Outpatient Management of Febrile Neutropenia

SAN DIEGO, California—Clinical trials over the last decade have led
to the development of pathways in which certain febrile neutropenic cancer
patients are managed as outpatients. At M. D. Anderson Cancer Center, advanced
practice nurses (APNs) take an active, complex role in the management of these
patients. Their role was summarized in a poster presentation at the Oncology
Nursing Society’s 26th Annual Congress (abstract 227).

"Clinical trials have shown there is a subset of patients who are best
treated at home, but they have to come back to the hospital to be
checked," said Eva Lu T. Lee, MSN, RN, CS, ANP, OCN, an M. D. Anderson
Emergency Center advanced practice nurse.

These are patients with solid tumors—sarcomas, breast cancer, lung cancer,
genitourinary cancers, and gastrointestinal cancers. "Their neutropenia is
not prolonged. The leukemia, lymphoma, and bone marrow transplant patients are
in more danger, and so they are automatically admitted to the hospital,"
said Ms. Lee, lead author of the analysis of the APN’s role in this setting.

Approximately 40% of the patients presenting with fever at the M.D. Anderson
Emergency Center are neutropenic, according to her analysis. Patients with an
absolute neutrophil count of 1,000 or less are grouped according to the
expected duration of their neutropenia, their cancer type, and any other
comorbid conditions.

To be eligible for treatment as an outpatient, the patient must live within
30 miles of the hospital and have a 24-hour companion, a telephone, and
transportation.

The oral outpatient treatment is amoxicillin/clavulate potassium (Aug-mentin)
plus ciprofloxacin (Cipro) or clindamycin (Cleocin)/ciprofloxacin. The
intravenous outpatient treatment is clindamycin/ceftazidime or clindamycin/aztreonam
(Azactam).

After the initial clinic visit when the patient presents with a fever, those
selected for outpatient treatment must return to the Emergency Center for the
next 2 days for reevaluation. At those visits, they are seen by the physician
and by the advanced practice nurse. On the fourth, fifth, and sixth day, the
nurse checks them by phone and tracks the results of laboratory and other
tests. On the seventh day, the physician and nurse see patients for their final
evaluation.

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