At-Home Management of Adult Patients Following Consolidation Chemotherapy for Acute Myeloid Leukemia

Background: Consolidation chemotherapy for adult patients with acute myeloid leukemia (AML) who have achieved a complete response after induction treatment is associated with prolonged, severe neutropenia and a high incidence of infections. In our center, patients were historically followed up during the neutropenic period at the day care unit, usually every 2 or 3 days, where they had routine laboratory tests, blood transfusions, central venous catheter management and medical checkups. Since this strategy was associated with a high incidence of febrile episodes that lead to hospital readmissions with some patients dying due to infectious complications, we designed a specific program for patients with AML receiving consolidation therapy including a specialized at-home management.

Patients and Methods: Since March 2011, all consecutive patients with AML without significant co-morbidities or active febrile complications who received consolidation chemotherapy and lived within 60 minutes of the hospital were included in the at-home program (AHP). During the neutropenic period, a specialized nurse took care of every patient daily, either visiting the patient at home or by phone. A record of the vital signs, routine laboratory tests, central venous catheter management and administration of intravenous medication was kept regularly by the nurse. Antibiotic prophylaxis consisted of oral levofloxacin (500 mg daily), oral posaconazole (200 mg, three times per day) and intravenous ceftriaxone during the neutropenic (<0.5 x10⁹/L) period. The hematologist in charge coordinated the assistance from the hospital. Most complications, mainly febrile episodes, were managed directly 24 hours a day at the Hematology Department instead of the Emergency Unit. If the patient remained hemodynamically stable without focal infection, treatment was continued at-home. The results of the AHP were compared with a historical cohort of patients (2006-2011) who received the same chemotherapy scheme but were managed at day care unit with the standard outpatient program.

Results: Up until February 2014, 29 out of 31 (94%) patients were included in the AHP, with a total of 60 episodes. Only 2 patients were excluded from the program, one because of lack of informed consent and the other due to an active febrile complication. The control group consisted of 40 out of 42 (98%) patients (56 episodes in total), who received consolidation treatment following the standard outpatient from May 2004 to March 2011. Median duration of severe neutropenia was of 11 (4-34) days in the AHP group compared with 18 (2-55) days in the control group (p<0.001), with no differences in the duration of the severe thrombocytopenia. In the AHP group, febrile episodes were documented in 17 (28%) episodes and only in 3 of them hospital readmission was necessary (5%). No deaths occurred in the AHP group during the study period. Eighty-two per cent of patients in the control group presented with fever and all of them were readmitted (p<0.001), with a median duration of hospitalization of 16 (0-34) days per episode, that supposed a total of 744 days. Three (5%) patients died from infections during the neutropenic period in the historical control group.

Conclusion: At-home management after administration of consolidation therapy in adult patients diagnosed with AML is feasible in most patients. It is associated to a lower incidence of febrile complications and readmissions, contributing to increase safety for patients and optimizing hospital resources.