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
Definition...
...r is defined as a single oral temper...
Diagnosis and Assessment
...iagnosis and Assessme...
...k Assessment...
...sk stratification is a recommended starti...
...of risk for complications of severe infection sh...
...ssment may determine type of empirical ant...
...atients — those with anticipated prolonged...
...patients — those with anticipat...
...l risk classification may be performed...
...e MASCC Risk-Index ScoreHaving trouble viewing...
...e maximum value of the score is 26. Sco...
Tests and Cultur...
...y tests should include a complete blood...
...2 sets of blood cultures are recommended: O...
...ood culture volumes should be limited to...
...e specimens from other sites of suspected i...
...aph is indicated for patients with...
...iric Antibiotic Th...
...ts require hospitalization for IV e...
...her antimicrobials (aminoglycosides...
...other agents active against aerobic Gram-positiv...
...ns to initial empirical therapy may be consid...
...sider early addition of vancomycin, linezo...
...arly addition of linezolid or daptomyci...
...s: Consider early use of a carbapenem (B, III)6...
...: Consider early use of polymyxin/...
...st penicillin-allergic patients tolerate cepha...
...rile neutropenic patients who have...
...sk patients should receive initial oral or I...
in combination is recommended for oral empi...
...egimens, including levofloxacin or ciproflo...
...iving fluoroquinolone prophylaxis sho...
...ission or continued stay in the hosp...
...ying Antibiotic Ther...
...ions to the initial antibiotic regimen s...
...ined persistent fever in an otherwise stable pa...
...nical and/or microbiological infectio...
...other Gram-positive coverage was star...
...who are hemodynamically unstable should ha...
...nts who have been started on IV or oral antib...
...n IV-to-oral switch in antibiotic re...
...pitalized patients who meet low-risk cri...
...f fever persists or recurs within 48...
...tifungal coverage should be considered...
...uration of Antibiotic Therapy...
In patients with clinically or microbi...
In patients with unexplained fever, it is reco...
...ely, if an appropriate treatment course has be...
...tibiotic Prophylax...
...quinolone prophylaxis should be con...
...Levofloxacin and ciprofloxacin have been...
...am-positive active agent to fluoroquinolo...
...erial prophylaxis is NOT routinely re...
...iric or Pre-Emptive Antifungal Therap...
...gh Ris...
...cal antifungal therapy and investigation for in...
Data are insufficient to recommend a specif...
...mptive antifungal management is acce...
Low Ri...
...n low-risk patients, the risk of invasiv...
...ifungal Prophyla...
...h Risk...
...ophylaxis against Candida infections...
...hylaxis against invasive Aspergillus i...
...active agent is recommended in patients with prio...
...prolonged neutropenic periods of at least...
...d period of (C, III)659...
...ow Risk
...prophylaxis is NOT recommended for patien...
...viral Prophyla...
...simplex virus (HSV)-seropositive pati...
...eatment for HSV or varicella-zoster virus...
...virus testing (including influenz...
Yearly influenza vaccination with ina...
...f vaccination is not established, but serolog...
...us infection should be treated with neu...
...n the setting of an influenza exposure or...
...t of RSV in neutropenic patients with...
Hematopoietic Growth Factors (G...
...rophylactic use of myeloid colony-sti...
...are not generally recommended for t...
...ssociated Bloodstream Infections (CLABSI)...
...ferential time to positivity (DTP) > 120 minutes...
...caused by S. aureus, P. aeruginosa, fungi, or myco...
...moval is also recommended for tunnel infection or...
...cumented CLABSI caused by coagulase-nega...
...ndocarditis, septic thrombosis (A, III)6...
persistent bacteremia or fungemia occurrin...
for other (C, III)65...
...ce hand hygiene, maximal sterile barrier precaut...
...ental Precautions...
...ygiene is the most effective means of preven...
...ier precautions should be followed for all...
...single-patient) rooms (B, II...
...HSCT recipients should be placed in rooms...
...dried or fresh flowers should NOT be a...
Hospital work exclusion policies shoul...
...Bacterial Pathogens in Neutropeni...
Treatment
...atment...
...e 3. Antimicrobials Frequently UsedHaving trouble...
...e 4. Indications for Addition of Gram-po...
...itial Management of Fever and Neutropenia...
...sess After 2-4 Days of Empirical Antibiotic T...
...High Risk Patient with Fever After 4 Days...