Postinduction Supportive Care of Pediatric Acute Myelocytic Leukemia: Should Patients be Kept in the Hospital?

Abstract

Children with AML become profoundly neutropenic while they undergo remission induction chemotherapy. It is unknown whether these children should be kept in the hospital while they are severely neutropenic to prevent life-threatening complications associated with neutropenia and reduce fatality. We at our institution routinely discharge patients after completing remission induction chemotherapy in the presence of profound neutropenia, unless it is clinically contraindicated. We reviewed all AML patients who were consecutively treated at our hospital from 1989 to 2011. Thirteen patients were electively discharged after completion of induction I chemotherapy. Of the 13, 4 died due to relapse or complications of stem cell transplants (not due to neutropenia related complications). Another eight are long term survivors. In this very small series, discharge from the hospital even though patients were severely neutropenic did not adversely affect the survival.

A comparison of resource utilization following chemotherapy for acute myeloid leukemia in children discharged versus children that remain hospitalized during neutropenia

“…This variation in practice is consistent with a recent survey of supportive care approaches among COG institutions and likely reflects the dearth of studies to compare the effectiveness of the two strategies in pediatric AML populations. One pediatric study found similar rates of mortality for outpatient versus inpatient management of neutropenia following AML induction chemotherapy which is consistent with our findings. Another study evaluating outpatient versus inpatient AML intensification chemotherapy found fewer days of febrile neutropenia and less antimicrobial use among outpatients than children receiving inpatient treatment .…”

“…However, a recent survey of pediatric supportive care practices suggests that up to one‐third of pediatric AML patients are discharged early to outpatient management during postchemotherapy neutropenia . While outpatient supportive care in this population has only been examined in a single study of 26 patients , several studies of adult AML patient populations suggest that outpatient management during neutropenia may be safe and feasible . Early hospital discharge was associated with fewer febrile episodes , reduced use of intravenous antibiotics and comparable mortality .…”

Comparison of in-patient costs for children treated on the AAML0531 clinical trial: A report from the Children's Oncology Group

“…Pediatric patients with AML traditionally remain hospitalized during treatment courses until ANC recovery to reduce infectious complications. However, studies suggest that outpatient management is safe and feasible for low‐risk adult and pediatric patients with AML . Furthermore, studies assessing the outpatient management of febrile neutropenia in adult and pediatric cancer populations and home chemotherapy treatment for pediatric ALL demonstrate reduced costs and improved quality of life for patients and their families .…”

“…However, studies suggest that outpatient management is safe and feasible for low-risk adult and pediatric patients with AML. [23][24][25][26] Furthermore, studies assessing the outpatient management of febrile neutropenia in adult and pediatric cancer populations and home chemotherapy treatment for pediatric ALL demonstrate reduced costs and improved quality of life for patients and their families. [27][28][29][30][31] In this context, our results suggest that judicious use of outpatient management may have distinct advantages, including cost savings.…”

Infection Features of Acute Leukemia Patients During Induction Chemotherapy: A Retrospective Analysis of 203 Cases

“…The difference was not significant (P = 0.59). However, it has been demonstrated that [28][29][30] , no matter AL patient achieves CR after chemotherapy, or the patient was without clinical contraindications, and even with severe neutropenia, it could not affect the discharge. But we need more clinical validation to confirm this conclusion.…”