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
...Definitions...
...r is defined as a single oral temperatur...
Diagnosis and Assessment
...Diagnosis an...
Risk Ass...
...k stratification is a recommended...
...of risk for complications of severe i...
...isk assessment may determine type of empiri...
...gh-risk patients — those with anticipa...
...s — those with anticipated brief (≤ 7 d...
...classification may be performed using t...
...MASCC Risk-Index Score Chara...
...he maximum value of the score is 26. Scor...
...Tests and...
...ratory tests should include a complete bl...
At least 2 sets of blood cultures are...
Blood culture volumes should be limit...
...specimens from other sites of sus...
...est radiograph is indicated for patients w...
...patients require hospitalization for IV empi...
...r antimicrobials (aminoglycosides, fluoro...
...n (or other agents active against aerobic...
...ons to initial empirical therapy may be c...
...RSA: Consider early addition of vancomycin, linezo...
...early addition of linezolid or dap...
...ider early use of a carbapenem (B, III)6...
...sider early use of polymyxin/colistin or ti...
Most penicillin-allergic patients tolerate cep...
...febrile neutropenic patients who h...
...ow-risk patients should receive initial oral...
...ation is recommended for oral empirical treatm...
...regimens, including levofloxacin or cipr...
...atients receiving fluoroquinolone pr...
...al re-admission or continued stay in the hospi...
...Modifying A...
...cations to the initial antibiotic regime...
...sistent fever in an otherwise stable patient...
...cumented clinical and/or microbiological...
...f vancomycin or other Gram-positive cove...
...ts who are hemodynamically unstabl...
...ients who have been started on IV or o...
...-to-oral switch in antibiotic regim...
...lected hospitalized patients who mee...
...er persists or recurs within 48 hours...
...fungal coverage should be considered in high...
...Duration...
...s with clinically or microbiologic...
...patients with unexplained fever, it is...
...ternatively, if an appropriate treatment...
...Antibiotic Proph...
...prophylaxis should be considered for high-risk pa...
...in and ciprofloxacin have been evaluated mo...
...ram-positive active agent to fluoroquinolone pr...
...ial prophylaxis is NOT routinely recommen...
...Empiric or Pre-E...
...High...
...ngal therapy and investigation for...
...a are insufficient to recommend a s...
...fungal management is acceptable as an alte...
Low R...
...-risk patients, the risk of invasive...
...Antifungal Prophylaxis...
...High Risk...
...rophylaxis against Candida infection...
...s against invasive Aspergillus infections with pos...
...ld-active agent is recommended in p...
...olonged neutropenic periods of at least 2...
...onged period of (C, III)659
...Low Ri...
...phylaxis is NOT recommended for patients in whom...
...Antiviral Prop...
...erpes simplex virus (HSV)-seropositive patient...
...ntiviral treatment for HSV or varicella-zoster vir...
Respiratory virus testing (including...
...luenza vaccination with inactivated va...
...al timing of vaccination is not esta...
...a virus infection should be treated with neura...
...ng of an influenza exposure or outbre...
...ine treatment of RSV in neutropeni...
...Hematopoietic Growth...
...phylactic use of myeloid colony-stimul...
...s are not generally recommended for treatm...
...C...
...al time to positivity (DTP) > 120 minutes of...
...aused by S. aureus, P. aeruginosa, fungi, o...
Catheter removal is also recommended for tunnel in...
...documented CLABSI caused by coagula...
...tis, septic thrombosis (A, III)659
...teremia or fungemia occurring > 72 ho...
...her (C, III)659
...nd hygiene, maximal sterile barrier...
...Environm...
...giene is the most effective means of pr...
...rier precautions should be followed...
...-patient) rooms (B, III)659...
...T recipients should be placed in rooms with > 12...
Plants and dried or fresh flowers should NOT...
...pital work exclusion policies should be des...
.... Common Bacterial Pathogens in Neutropenic Patien...
Treatment
...Antimicrobials Frequently Used...
...4. Indications for Addition of Gram-positive Acti...
...gure 1. Initial Management of Fever and N...
...Reassess After 2-4 Days of Empirical A...
...h Risk Patient with Fever After 4 Days of...