Improved Outcome of Acute Leukemia Patients Followed up In out-Patient Setting After High Dose Ara-C (HDAC) Consolidation with Infection Prophylaxis Strategies

Outpatient care of patients with malignancies has become increasingly common and is driven by health care costs, increased demand for existing inpatient resources, improved supportive care and patient wishes to spend the least amount of time in the inpatient setting. High dose Ara-C/cytosine arabinoside (HIDAC) consolidation is frequently used for most acute leukemias. Typically HIDAC consists of 12 hourly IV administrations of 3 grams/m2 dose of Ara-C every other day for a total of 6 doses. One of the authors (AS) had earlier pioneered the idea of giving HIDAC and discharging the patients for out-patient follow up. Prince Sultan Hematology Oncology Centre (PSHOC), Riyadh adopted “post-HIDAC early discharge” policy in late 2006 and later found that it is safe and has resulted in huge hospital-days saving in comparison to our contemporary policy of keeping the patients in hospital till they recover counts after going through nadir. Lately we have also added G-CSF along with antimicrobial prophylaxis during neutropenia for preventing/reducing the period of febrile neutropenia (FN) after HIDAC chemotherapy. Here we present the results of our practice improvement strategy analysis to evaluate the effectiveness of these new measures.

Sixty five patients receiving 96 cycles of HIDAC between October 2004 and March 2009 were divided in three groups: First cohort of 23 patients (group I) were discharged without any kind of prophylaxis after HIDAC (35 cycles); and 30 patients in later cohort (group II) received prophylactic ciprofloxacin, fluconazole and acyclovir once absolute neutrophil count (ANC) dropped to <1.0 × 10⁹/L, and GCSF 300 mcg S/C daily once ANC was <0.5 × 10⁹/L until ANC recovered (>1.0 × 10⁹/L) after HIDAC (44 cycles), and the last cohort (group III) consisted of 12 patients who stayed in the hospital after HIDAC (17 cycles) till count recovery. Discharged patients stayed in the vicinity of Riyadh city and were followed-up in outpatient treatment unit (OTU) every other day. All patients were given detailed instructions and a medical alert card to provide them fast access to emergency care. Any patient who had neutropenic fever or judged as septic was admitted. Data on number of total hospital inpatient days for each HIDAC cycle, type of infection developed, and any mortality & serious morbidity requiring ICU care were recorded.

In group I, all of the 23 patients who received 35 cycles of HIDAC were re-admitted in all cycles for febrile neutropenia (33/35) and/or severe thrombocytopenia (2/35) until they recovered. The median of their inpatient hospital days was 15 (range 9–23). There was one septic shock that required 4 days of ICU stay. In group II, 30 patients received 44 cycles of HIDAC along with the prophylaxis and 21/44 (47.7%) cycles were without febrile neutropenia. In 23/44 cycles (52.2 %) febrile neutropenia required shorter admission for a median of 12 days (range 7–23). However 8/10 positive blood cultures in group II revealed ciprofloxacin resistant E. coli, and one each revealed K. pneumonia, and S. viridians. One patient was admitted with non documented fever noted at home, one with dental abscess, and HSV PCR was positive from mouth wash in one patient. In group III comprising of 10 of our historic patients, who received 17 cycles of HIDAC, 11 cycles (64.7%) were associated with FN.

The currently reported policy of post-HIDAC early discharge with infection prophylaxis is feasible, safe, and may be more cost effective as it resulted in saving more hospital days: compared to a median of 26 days in group III and a median of 15 days in group I, patients in group II with infection prophylaxis required only a median of 12 days of hospitalization. GCSF and antimicrobial prophylaxis have important value in decreasing the incidence of febrile neutropenia but increase in ciprofloxacin resistant E. coli bacteremia is worrisome and may need change in type of prophylactic antibiotic (e.g. to levofloxacin).

No relevant conflicts of interest to declare.