Low-risk Fever and Neutropenia in Children With Cancer: Safety and Efficacy of Oral Antibiotics in an Outpatient Setting

Phase 3

Terminated

• Conditions: Fever; Neutropenia; Cancer
• Interventions: Drug: ciprofloxacin and amoxicillin; Drug: i.v. antibiotics; Procedure: inpatient management; Procedure: Outpatient management

• Registration Number: NCT00107081
• Lead Sponsor: Swiss Pediatric Oncology Group

Brief Summary

The purpose of this study is to determine whether, in children with cancer presenting with fever in severe chemotherapy-induced neutropenia at low risk for medical complications, oral antibiotics in an outpatient setting after an initial phase of intravenous antibiotics and in-hospital observation for 8 to 22 hours, is not inferior as to safety and efficacy compared to continued intravenous antibiotics given in-hospital.

Detailed Description

Details on antimicrobial therapy

* At presentation with FN (fever and neutropenia) and during an initial inpatient observation period of 8 to 22 hours, empirical intravenous broad-spectrum antibiotics are given. Type and dosage are chosen by the treating physician.

* Patients randomized to continued intravenous antibiotics continue with these antibiotics.

* Patients randomized to oral antibiotics receive a combination of oral ciprofloxacin (25 to 30 mg/kg/day, top dose 1500 mg/day) plus oral amoxicillin (65 to 80 mg/kg/day, top dose 2250 mg/day), both given in two doses per day.

* In both groups, the study gives guidelines (for certain situations) and rules (for other situations) when to change and when to stop antibiotics.

Details on clinical and laboratory controls

* During antibiotic therapy, patients are seen daily, either as inpatients or as outpatients according to randomization. Complete blood counts are performed at least every second day.

* After stopping antibiotic therapy and until resolution of severe neutropenia (if applicable), patients are seen every other day, with a complete blood count.

* Patients randomized to outpatient management have the possibility to contact at any time of the day (and night) a pediatric oncologist in case of problems, in order to discuss necessity for emergency control and/or rehospitalization.

Study Timeline

• Study Start: 2004-01
• Study First Submitted: 2005-04-04
• Study First Submitted QC: 2005-04-04
• Study First Posted: 2005-04-05
• Primary Completion: 2007-12
• Study Completion: 2007-12
• Status Verified: 2020-10
• Last Update Submitted: 2020-10-29
• Last Update Posted: 2020-11-02

Recruitment & Eligibility

• Status: TERMINATED
• Sex: All
• Target Recruitment: 70

Inclusion Criteria

• Chemotherapy because of malignancy
• Severe neutropenia (absolute neutrophil count ≤ 0.5x10E9/L)
• Fever (axillary temperature ≥ 38.5°C once or ≥ 38.0°C during ≥ 2 hours)
• Able to swallow oral medication
• Written informed consent from patients and/or parents

Exclusion Criteria

• Status post myeloablative chemotherapy
• Diagnosis: acute myeloid leukemia, B-cell acute lymphoblastic leukemia, or B-cell Non-Hodgkin lymphoma
• Bone marrow involvement by malignancy ≥ 25%
• Any comorbidity requiring hospitalization: [1] mean arterial blood pressure < 50 mmHg (up to 10 years) / < 60 mmHg (older than 10 years); [2] oxygen saturation < 94% at room air; [3] radiologically defined pneumonia; [4] focal bacterial infection; [5] blood cultures taken at presentation reported positive at reassessment; [6] need for inpatient treatment or observation due to any other reason, as judged by the physician in charge
• Ever shaking chills
• Ever axillary temperature ≥ 39.5°C
• Antibacterial treatment before presentation with fever and neutropenia (except for prevention against Pneumocystis jiroveci [formerly P. carinii] pneumonia)
• Modification or de novo institution of a prophylaxis against P. jiroveci pneumonia
• Modification or de novo institution of a therapy with G-CSF or GM-CSF.
• Allergy to ciprofloxacin and/or amoxicillin
• Serum creatinine level above the upper limit of normal range

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Experimental	ciprofloxacin and amoxicillin	Switch to outpatient p.o. antibiotics
Standard	inpatient management	Continued inpatient i.v. antibiotics
Standard	i.v. antibiotics	Continued inpatient i.v. antibiotics
Experimental	Outpatient management	Switch to outpatient p.o. antibiotics

Primary Outcome Measures

Name	Time	Method
Efficacy: Response without rehospitalization or changing randomized antibiotics (non-inferiority design, limit 10%)
Safety: No serious medical complication due to infection (death, treatment in ICU [Intensive Care Unit], potentially life-threatening complication) (non-inferiority-design, limit 3.5%)

Secondary Outcome Measures

Name	Time	Method
Improved prediction of low-risk episodes of fever and neutropenia
Description of characteristics of low-risk episodes of fever and neutropenia
Description of characteristics of high-risk episodes of fever and neutropenia (observational study part)

Trial Locations

Locations (4)

Pediatric Hematology/Oncology, University Children's Hospital; 🇨🇭 Zurich, Switzerland

Pediatric Hematology/Oncology, University Hospital St. Hedwig; 🇩🇪 Regensburg, Germany

Pediatric Hematology/Oncology, University Children's Hospital von Hauner; 🇩🇪 Munich, Germany

Pediatric Hematology/Oncology, Children's Hospital; 🇨🇭 Lucerne, Switzerland