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

...finitions...

...is defined as a single oral temperature me...


Diagnosis and Assessment

Diagnosis and Assess...

...k Assessment

...sk stratification is a recommended starting point...

...sk for complications of severe infection shoul...

...t may determine type of empirical antibi...

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

...w-risk patients — those with anticipated b...

...sk classification may be performed using the va...

.... The MASCC Risk-Index ScoreHaving troub...

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


...ests and Cultur...

...sts should include a complete blood count (C...

...east 2 sets of blood cultures are recommended...

...od culture volumes should be limited to < 1% of...

...ure specimens from other sites of sus...

...diograph is indicated for patients...


Empiric Antibiotic...

...k patients require hospitalization for IV empir...

...crobials (aminoglycosides, fluoroquinol...

...ncomycin (or other agents active against aerobic...

...ions to initial empirical therapy may be considere...

...A: Consider early addition of vancomycin, l...

...er early addition of linezolid or daptomycin (B,...

...Ls: Consider early use of a carbapene...

...Consider early use of polymyxin/co...

...ost penicillin-allergic patients tolerate cephal...

...brile neutropenic patients who have new si...

...isk patients should receive initial or...

...n combination is recommended for oral empi...

...oral regimens, including levofloxacin or ciprofl...

...ents receiving fluoroquinolone prophy...

...re-admission or continued stay in the hos...


Modifying Antibiotic Therap...

...ns to the initial antibiotic regimen should b...

...ined persistent fever in an otherwise stable patie...

Documented clinical and/or microbi...

...f vancomycin or other Gram-positive coverage w...

...ts who are hemodynamically unstable sh...

...patients who have been started on IV or oral...

...-oral switch in antibiotic regimen may be mad...

...hospitalized patients who meet low-risk crit...

...persists or recurs within 48 hours in...

...antifungal coverage should be consid...


...on of Antibiotic Therapy...

...with clinically or microbiological...

...ith unexplained fever, it is recommended th...

...y, if an appropriate treatment course...


...ibiotic Prophylaxi...

Fluoroquinolone prophylaxis should be cons...

Levofloxacin and ciprofloxacin h...

Addition of a Gram-positive active agent to...

...tibacterial prophylaxis is NOT routinely rec...


...or Pre-Emptive Antifungal Therap...

...gh Risk

...l antifungal therapy and investigation for...

...ufficient to recommend a specific empiric...

...ve antifungal management is acceptable...

...ow Ris...

...isk patients, the risk of invasive fu...


...ifungal Prophylaxis...

...gh Risk

...nst Candida infections is recommended i...

Prophylaxis against invasive Aspergillu...

...-active agent is recommended in patients w...

...ticipated prolonged neutropenic periods...

...d period of (C, III)659...

...ow Risk...

...l prophylaxis is NOT recommended for patients in...


...iral Prophylaxis...

...x virus (HSV)-seropositive patients undergo...

...treatment for HSV or varicella-zoste...

...s testing (including influenza, parainfluenz...

...uenza vaccination with inactivated vaccine is re...

...timing of vaccination is not estab...

...enza virus infection should be treated...

...n the setting of an influenza exposure...

...ment of RSV in neutropenic patients w...


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

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

...not generally recommended for treatment of...


...al Line-Associated Bloodstream Infections (CLABS...

...fferential time to positivity (DTP) > 120 minute...

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

...ter removal is also recommended for tunnel infect...

...or documented CLABSI caused by coagulase-ne...

...ndocarditis, septic thrombosis (A, III)65...

...istent bacteremia or fungemia occurring >...

...ther (C, III)65...

...ce hand hygiene, maximal sterile barrier pr...


...nmental Precaution...

...is the most effective means of prevent...

...dard barrier precautions should be followed for a...

...ie, single-patient) rooms (B, II...

...recipients should be placed in rooms wit...

...or fresh flowers should NOT be allowed in the ro...

Hospital work exclusion policies should b...

...le 2. Common Bacterial Pathogens in Neutrope...


Treatment

...eatment...

Table 3. Antimicrobials Frequently Used...


...ications for Addition of Gram-positive Act...


...gure 1. Initial Management of Feve...


...ess After 2-4 Days of Empirical Antibioti...


...isk Patient with Fever After 4 Day...