Selective discharge of patients with acute myeloid leukemia during chemotherapy-induced neutropenia

It is common practice for patients with acute myeloid leukemia (AML) to be observed in hospital during the entire nadir after intensive chemotherapy. In an attempt to lessen the likelihood of developing infections with hospital acquired pathogens, we usually discharge patients upon completion of chemotherapy and follow them as outpatients. They are readmitted if fever develops. We evaluated the feasibility and safety of this practice.

We studied 29 patients with AML (median age 40 years, range 16-63) who were treated with intensive remission-induction and consolidation chemotherapy. Afebrile patients not receiving antibiotics were discharged immediately following chemotherapy and were followed every 3-4 days at the day care unit. Patients were instructed to return immediately if fever rose to 38.2 degrees C or a fever of 38 degrees C persisted for 2 hr. The 29 patients received a total of 86 courses. Following 50 courses, patients were discharged. These 50 ambulatory nadir periods (ANPs) were monitored.

Median WBC and platelet counts on discharge were 2,900 per cubic millimeter (range 300-8,300) and 137,000 per cubic millimeter (range 17,000-618,000), respectively. Mean traveling time from the hospital by car was 1.6 hr (range 15 min-3 hr). In three of the 50 ANPs (6%), patients were not readmitted during their entire nadir. During 47 of the ANPs, patients returned to the hospital (because of fever in 44 cases), a mean of 7.2 days (range 1.0-12.7 days) after discharge. In 45 ANPs, patients were readmitted in good general condition. Four patients had life-threatening complications. Two patients were admitted in septic shock due to delay in seeking admission, but rapidly recovered. Two other patients died, one of cardiogenic shock within 24 hr of readmission and one 24 days later. Only one of the 11 gram negative bacteria cultured was resistant to mezlocillin and gentamicin. After 45 ANPs, patients were discharged a mean of 12.2 days (range 5-42 days) following readmission. We estimate that approximately 383 hospital days were saved by this policy, a mean of 7.6 days per patient, representing 16% of total inpatient hospital days.

For AML patients who are reliable and without complicating medical conditions, selected discharge following chemotherapy is a low-risk practice and may reduce the incidence of infection with resistant hospital-acquired pathogens.