Fever and Neutropenia in Cancer Patients
Key Points
Key Points
10% to 50% of patients with solid tumors and > 80% in those with hematologic malignancies will develop fever during one or more chemotherapy cycles associated with neutropenia.
All patients who present with fever and neutropenia should be treated empirically, swiftly and broadly, with antibiotics primarily directed against serious Gram-negative pathogens that may cause life-threatening sepsis.
Clinically documented infections occur in 20-30% of febrile episodes.
Common sites of tissue-based infection include the intestinal tract, lung, and skin.
Bacteremia occurs in 10-25% of all patients, with most episodes occurring in the setting of prolonged or profound neutropenia (absolute neutrophil count less than 100 neutrophils/mm3).
Resistant Gram-positive pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), have become more common and are the most prevalent resistant isolates in some centers, accounting for 20% to over 50% of episodes, respectively.
Penicillin-resistant strains of S. pneumoniae and of viridans group streptococci are less common but may cause severe infections.
Fungi are rarely identified as the cause of first fever early in the course of neutropenia. Rather, they are encountered after the first week of prolonged neutropenia and empirical antibiotic therapy.
Definitions
...efinition...
...er is defined as a single oral temperature...
Diagnosis and Assessment
...s and Assessment...
...k Assessment...
...ion is a recommended starting point for managing p...
...risk for complications of severe in...
...sessment may determine type of empirical...
...patients — those with anticipated prolon...
...ents — those with anticipated brief (≤...
...l risk classification may be performed u...
...1. The MASCC Risk-Index ScoreHaving trouble vi...
...mum value of the score is 26. Scores...
...and Cultures...
...s should include a complete blood cou...
...t 2 sets of blood cultures are recommended: O...
...lture volumes should be limited to < 1% of total b...
...ture specimens from other sites of suspected inf...
...hest radiograph is indicated for p...
...Antibiotic Therap...
...k patients require hospitalization...
...ials (aminoglycosides, fluoroquinolones and/or va...
...mycin (or other agents active against a...
...ions to initial empirical therapy may be con...
...arly addition of vancomycin, linezo...
...Consider early addition of linezolid or...
...: Consider early use of a carbapenem (B...
...er early use of polymyxin/colistin or...
...ost penicillin-allergic patients tolerate cep...
...ropenic patients who have new signs or...
...atients should receive initial oral or IV empiric...
in combination is recommended for oral empi...
...ral regimens, including levofloxacin or ciprofl...
...ving fluoroquinolone prophylaxis should not re...
...ssion or continued stay in the hospital i...
...Antibiotic Therapy...
...ifications to the initial antibiotic regimen s...
...explained persistent fever in an otherwise...
...nical and/or microbiological infections sh...
...vancomycin or other Gram-positive coverage was sta...
...atients who are hemodynamically unstable should...
Low-risk patients who have been sta...
...o-oral switch in antibiotic regimen...
...ed hospitalized patients who meet low-risk cri...
...ersists or recurs within 48 hours in o...
...l antifungal coverage should be considered i...
...n of Antibiotic Therapy...
...patients with clinically or microbiologically...
...tients with unexplained fever, it is rec...
...ely, if an appropriate treatment course...
...biotic Prophylaxis
...oquinolone prophylaxis should be considered...
...ofloxacin and ciprofloxacin have been evaluated...
...ram-positive active agent to fluoroquinolone pr...
...prophylaxis is NOT routinely recommended f...
...ric or Pre-Emptive Antifungal Therapy...
High Ris...
...ngal therapy and investigation for invas...
...a are insufficient to recommend a specific...
...ntifungal management is acceptable...
...w Risk...
In low-risk patients, the risk of inv...
...gal Prophylaxis...
...gh Ris...
...inst Candida infections is recommended in patie...
...phylaxis against invasive Aspergillus infe...
...d-active agent is recommended in pati...
...prolonged neutropenic periods of at le...
...onged period of (C, III...
...ow Risk
...prophylaxis is NOT recommended for patien...
...tiviral Prophyl...
...x virus (HSV)-seropositive patients undergoin...
...tment for HSV or varicella-zoster virus (VZV) is i...
...espiratory virus testing (including influe...
...enza vaccination with inactivated v...
...al timing of vaccination is not established,...
...luenza virus infection should be treated...
...setting of an influenza exposure or outbreak,...
...utine treatment of RSV in neutropen...
Hematopoietic Growth Factors (G-CSF or GM-CS...
...actic use of myeloid colony-stimulating f...
...e not generally recommended for tr...
...e-Associated Bloodstream Infections (CLABSI)...
...time to positivity (DTP) > 120 minutes of...
...r CLABSI caused by S. aureus, P. aeruginos...
...ter removal is also recommended for tunnel infect...
...cumented CLABSI caused by coagulase-negative st...
...itis, septic thrombosis (A, III)...
...tent bacteremia or fungemia occurr...
...her (C, III)659...
...ygiene, maximal sterile barrier precautions, and...
...nvironmental Preca...
...ygiene is the most effective means o...
...er precautions should be followed for all pa...
...ingle-patient) rooms (B, III)...
...HSCT recipients should be placed in ro...
...ed or fresh flowers should NOT be allo...
...al work exclusion policies should be...
...mmon Bacterial Pathogens in Neutropenic Patie...
Treatment
...reatme...
...Antimicrobials Frequently UsedHaving trouble vie...
...able 4. Indications for Addition of Gram-positi...
Figure 1. Initial Management of Fever and...
...Reassess After 2-4 Days of Empirical Antibiotic...
...gure 3. High Risk Patient with Fever Af...