Fever and Neutropenia in Cancer Patients

Publication Date: February 15, 2011

Key Points

Key Points

Fever during chemotherapy-induced neutropenia may be the only indication of a severe underlying infection since signs and symptoms of inflammation typically are attenuated.

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

Definition...

...d as a single oral temperature measur...


Diagnosis and Assessment

...sis and Assessment...

...k Assessme...

...stratification is a recommended starting point f...

...f risk for complications of severe infection shou...

...essment may determine type of empiric...

...igh-risk patients — those with a...

...-risk patients — those with antici...

...classification may be performed using the validate...

...CC Risk-Index ScoreHaving trouble viewing table?...

...: The maximum value of the score is 26. Scores b...


...ts and Cultures...

...ts should include a complete blood c...

...ets of blood cultures are recommended: One se...

...ulture volumes should be limited to < 1% of...

...specimens from other sites of suspected infec...

...diograph is indicated for patients with respirato...


...piric Antibiotic Thera...

...atients require hospitalization for IV em...

...robials (aminoglycosides, fluoroquinolones an...

...or other agents active against aerobic G...

...ons to initial empirical therapy may be conside...

...der early addition of vancomycin, linezolid or da...

...early addition of linezolid or daptomyc...

...sider early use of a carbapenem (B, III)659...

KPCs: Consider early use of polymyxin/coli...

...-allergic patients tolerate cephalosporins, but...

...neutropenic patients who have new signs or symp...

...s should receive initial oral or IV e...

...combination is recommended for oral empirical...

...ens, including levofloxacin or ciprofloxaci...

...receiving fluoroquinolone prophylaxis should not...

...ssion or continued stay in the hospital...


...odifying Antibiotic The...

...to the initial antibiotic regimen should be gu...

...sistent fever in an otherwise stable patient ra...

...ented clinical and/or microbiological infec...

...ncomycin or other Gram-positive coverage was...

...who are hemodynamically unstable should...

...ow-risk patients who have been started on...

...IV-to-oral switch in antibiotic regimen...

...pitalized patients who meet low-risk criteria m...

...ersists or recurs within 48 hours in out...

...cal antifungal coverage should be consi...


...f Antibiotic Therapy...

...atients with clinically or microbiologically...

...patients with unexplained fever, it is recommende...

...f an appropriate treatment course has been comple...


...tibiotic Prophylaxi...

...luoroquinolone prophylaxis should be consid...

...oxacin and ciprofloxacin have been evaluated...

...ddition of a Gram-positive active agent to flu...

...terial prophylaxis is NOT routinely r...


...e-Emptive Antifungal Therapy

High Risk

...rical antifungal therapy and investig...

...re insufficient to recommend a specific empirica...

...antifungal management is acceptable as an alter...

...ow Risk...

...atients, the risk of invasive fungal infections i...


Antifungal Prophyl...

...gh Ris...

...axis against Candida infections is...

...axis against invasive Aspergillus infections...

...owever, a mold-active agent is recom...

...prolonged neutropenic periods of at lea...

...prolonged period of (C,...

Low Risk

...tifungal prophylaxis is NOT recommended...


...iviral Prophylaxi...

...implex virus (HSV)-seropositive patients unde...

...iral treatment for HSV or varicella-zoster...

...irus testing (including influenza, par...

...fluenza vaccination with inactivated vaccin...

...of vaccination is not established, but ser...

Influenza virus infection should be tre...

...ing of an influenza exposure or out...

...nt of RSV in neutropenic patients with uppe...


...opoietic Growth Factors (G-CSF or GM-CSF)...

...use of myeloid colony-stimulating factors (...

...enerally recommended for treatment of...


...e-Associated Bloodstream Infections (CLABSI...

Differential time to positivity (DTP) > 120 min...

...CLABSI caused by S. aureus, P. aeruginosa, fu...

Catheter removal is also recommended fo...

...umented CLABSI caused by coagulase-neg...

...ocarditis, septic thrombosis (A, III)659...

...bacteremia or fungemia occurring...

...her (C, III)659...

...and hygiene, maximal sterile barrie...


...nmental Precautions...

...iene is the most effective means of prev...

...andard barrier precautions should b...

...le-patient) rooms (B, III)659...

...eneic HSCT recipients should be placed in roo...

...nd dried or fresh flowers should NOT be allo...

...l work exclusion policies should be design...

...mmon Bacterial Pathogens in Neutro...


Treatment

...eatment

...e 3. Antimicrobials Frequently UsedHav...


...e 4. Indications for Addition of Gram-po...


...re 1. Initial Management of Fever and Neutropen...


...eassess After 2-4 Days of Empirical Antibiotic T...


...3. High Risk Patient with Fever After 4 Days of E...