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

...initions...

...defined as a single oral temperature measu...


Diagnosis and Assessment

...agnosis and Assessment

...k Assessment...

...ion is a recommended starting point for managing...

...risk for complications of severe inf...

...ssessment may determine type of empirical antibio...

...gh-risk patients — those with anticipated prolon...

...w-risk patients — those with anticipat...

...risk classification may be performed us...

...ble 1. The MASCC Risk-Index ScoreHaving trouble...

...um value of the score is 26. Scores below 21...


...sts and Culture...

...s should include a complete blood count (CB...

...ts of blood cultures are recommended: One...

...olumes should be limited to < 1% of...

...pecimens from other sites of suspected...

...radiograph is indicated for patients with respir...


...mpiric Antibiotic Therapy

...sk patients require hospitalization for IV empi...

...her antimicrobials (aminoglycosides, fluoroquinolo...

...mycin (or other agents active against a...

...s to initial empirical therapy may be con...

...ider early addition of vancomycin, linezol...

...onsider early addition of linezolid or dapt...

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

...nsider early use of polymyxin/colist...

...allergic patients tolerate cephalosp...

...openic patients who have new signs or symptoms s...

...sk patients should receive initial oral or I...

...n combination is recommended for oral empirical tr...

...r oral regimens, including levofloxacin o...

...ts receiving fluoroquinolone prophy...

Hospital re-admission or continued s...


...ifying Antibiotic The...

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

...lained persistent fever in an otherwise sta...

...cal and/or microbiological infections shoul...

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

...e hemodynamically unstable should have their antim...

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

...n IV-to-oral switch in antibiotic r...

...italized patients who meet low-risk criteria may...

...sists or recurs within 48 hours in outpatie...

...irical antifungal coverage should be...


...ration of Antibiotic...

...s with clinically or microbiologicall...

...atients with unexplained fever, it is reco...

...if an appropriate treatment course has been co...


Antibiotic Prophylaxis

...one prophylaxis should be considered for high-risk...

...n and ciprofloxacin have been evaluated mo...

...f a Gram-positive active agent to fluoro...

...prophylaxis is NOT routinely recomm...


...Pre-Emptive Antifungal Thera...

...gh Risk

...ifungal therapy and investigation for invasive fu...

...cient to recommend a specific empir...

...ive antifungal management is acceptable as...

...w Risk...

...atients, the risk of invasive fung...


...tifungal Prophylax...

High Ris...

Prophylaxis against Candida infections is r...

...axis against invasive Aspergillus infections with...

...d-active agent is recommended in patients with...

...prolonged neutropenic periods of at least 2...

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

...ow Risk...

Antifungal prophylaxis is NOT recommende...


...viral Prophylaxis...

...virus (HSV)-seropositive patients un...

...ent for HSV or varicella-zoster virus...

Respiratory virus testing (including...

...nfluenza vaccination with inactivated...

...timing of vaccination is not established, but se...

...virus infection should be treated with neuraminida...

...tting of an influenza exposure or outbreak,...

...e treatment of RSV in neutropenic patient...


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

...rophylactic use of myeloid colony-stimulating...

...ot generally recommended for treatment of establi...


Central Line-Associated Bloodstrea...

...al time to positivity (DTP) > 120 minutes of s...

...sed by S. aureus, P. aeruginosa, fungi, or my...

...r removal is also recommended for tunnel infection...

...CLABSI caused by coagulase-negative...

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

persistent bacteremia or fungemia occurring >...

...er (C, III)659...

Practice hand hygiene, maximal sterile barr...


Environmental Precau...

...is the most effective means of preventing...

...rrier precautions should be followed for al...

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

...T recipients should be placed in roo...

Plants and dried or fresh flowers should...

...clusion policies should be designed to encourage h...

...2. Common Bacterial Pathogens in Neutropenic...


Treatment

...reatmen...

...crobials Frequently UsedHaving trouble viewing ta...


...ndications for Addition of Gram-positive A...


...al Management of Fever and Neutropenia...


...e 2. Reassess After 2-4 Days of Empirical Ant...


...ure 3. High Risk Patient with Fever After...