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
Definitio...
...d as a single oral temperature measurement of ≥...
Diagnosis and Assessment
...osis and Assessme...
...isk Assessmen...
...tion is a recommended starting point for managing...
...risk for complications of severe infection shoul...
...isk assessment may determine type of emp...
...ts — those with anticipated prolonged (> 7 days...
...ients — those with anticipated brief (≤ 7...
...sification may be performed using the validated...
...The MASCC Risk-Index ScoreHaving tr...
...e maximum value of the score is 26. Score...
...and Cultures
...tests should include a complete blood c...
...east 2 sets of blood cultures are...
...d culture volumes should be limited to < 1% o...
...pecimens from other sites of suspected in...
...graph is indicated for patients with respiratory...
...c Antibiotic Therapy...
...gh-risk patients require hospitalizat...
...bials (aminoglycosides, fluoroquinolones and/or va...
...in (or other agents active against aero...
...cations to initial empirical therapy ma...
...arly addition of vancomycin, linezolid or dapto...
...early addition of linezolid or da...
...Ls: Consider early use of a carbapenem (B, III)659...
...s: Consider early use of polymyxin/colist...
...icillin-allergic patients tolerate cephalosporins...
...ebrile neutropenic patients who have...
...s should receive initial oral or IV...
...nation is recommended for oral empirical treatme...
...oral regimens, including levofloxacin or ci...
...ts receiving fluoroquinolone proph...
...re-admission or continued stay in the hospita...
...g Antibiotic Therapy...
...fications to the initial antibioti...
...persistent fever in an otherwise stable pat...
...d clinical and/or microbiological infecti...
...ycin or other Gram-positive coverage was star...
...s who are hemodynamically unstable should have the...
...risk patients who have been started on...
...o-oral switch in antibiotic regimen m...
...ed hospitalized patients who meet low...
...f fever persists or recurs within 4...
...antifungal coverage should be considered...
...of Antibiotic Therapy...
...with clinically or microbiologically documented...
...with unexplained fever, it is recommended t...
Alternatively, if an appropriate t...
...tibiotic Prophyla...
...prophylaxis should be considered f...
...cin and ciprofloxacin have been evaluat...
...ition of a Gram-positive active agent to flu...
...l prophylaxis is NOT routinely recom...
...Pre-Emptive Antifungal Therapy...
...h Risk...
Empirical antifungal therapy and investigatio...
...e insufficient to recommend a specific empiri...
...ptive antifungal management is acceptable as...
...ow Risk...
...low-risk patients, the risk of invasive fungal i...
...ngal Prophylaxis...
High Ri...
...inst Candida infections is recommended in p...
...gainst invasive Aspergillus infections...
...active agent is recommended in patien...
...cipated prolonged neutropenic periods of at least...
...d period of (C, III)659...
Low Ri...
Antifungal prophylaxis is NOT recommen...
...tiviral Prophylaxis...
...virus (HSV)-seropositive patients undergoing allog...
...treatment for HSV or varicella-zoste...
...virus testing (including influenza,...
...rly influenza vaccination with inactivate...
Optimal timing of vaccination is not estab...
...irus infection should be treated with neuraminid...
...ing of an influenza exposure or outbreak, neu...
...ne treatment of RSV in neutropenic patients...
...ietic Growth Factors (G-CSF or GM-CSF)...
...ic use of myeloid colony-stimulating f...
...t generally recommended for treatm...
...sociated Bloodstream Infections (CLABS...
...ntial time to positivity (DTP) > 120 minutes...
...d by S. aureus, P. aeruginosa, fungi, or...
...l is also recommended for tunnel inf...
...CLABSI caused by coagulase-negative...
...itis, septic thrombosis (A, III...
...bacteremia or fungemia occurring > 72 hour...
...her (C, III)659
...actice hand hygiene, maximal sterile b...
...ironmental Precaut...
...s the most effective means of preventi...
...precautions should be followed for all patients a...
...single-patient) rooms (B, III)659...
...ic HSCT recipients should be place...
...ts and dried or fresh flowers should NOT...
...tal work exclusion policies should be designe...
Table 2. Common Bacterial Pathogens...
Treatment
...atment...
...le 3. Antimicrobials Frequently UsedHav...
...Indications for Addition of Gram-positive Act...
...ial Management of Fever and Neutropenia...
...Reassess After 2-4 Days of Empirical...
...h Risk Patient with Fever After 4 Days of Empirica...