Oral therapy

As part of the trend toward risk stratification, and to avoid risks and costs of lengthy hospital-based care, there has been an increased interest in early discharge and even initial oral therapy.17 Randomized trials have demonstrated safety and efficacy of oral therapy in certain low-risk groups of patients.18 The presence of chills, hypotension, dyspnea, radiographic abnormalities, or localizing signs such as abdominal pain, or anything worrisome to the clinician immediately takes the patient out of the "low-risk" group. A multinational scoring system for identifying low-risk patients has been developed, which included the following: absence of symptoms or mild-to-moderate symptoms; absence of hypotension, dehydration, or chronic obstructive pulmonary disease; presence of solid tumor, absence of previous fungal infection in patients with hematologic malignancies, outpatient status, and age less than 60 years.19 Other factors cited as part of low-risk criteria include cancer in partial or complete remission, temperature less than 39 °C, normal chest X-ray, absence of rigors, respiratory rate 24 breaths/min or less, and absence of diabetes, confusion, mental status changes, or blood loss.

The oral combination most frequently used to treat fever and neutropenia is a combination of ciprofloxacin and amoxicillin-clavulanate.17,18 This combination is less useful at centers where there is already significant quinolone resistance. With any patient in whom oral therapy is used, the patient should be closely monitored and should be immediately placed on broad-spectrum i.v. antibiotics if fever or any other worrisome clinical change occurs.

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