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

...Definitions...

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


Diagnosis and Assessment

...Diagnosis and Assessme...

...Risk Assessm...

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

...risk for complications of severe infection sh...

...sment may determine type of empirical antibiot...

...sk patients — those with anticipated prolon...

...tients — those with anticipated brief (...

...lassification may be performed usin...

...e MASCC Risk-Index ScoreHaving trouble...

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


...T...

...ests should include a complete blood cou...

...least 2 sets of blood cultures ar...

...lumes should be limited to < 1% of total blo...

...specimens from other sites of suspected infectio...

...diograph is indicated for patients with respi...


...Empiric Antibiot...

...atients require hospitalization for IV em...

...er antimicrobials (aminoglycosides, fluoroquinol...

...ther agents active against aerobic Gra...

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

MRSA: Consider early addition of vanc...

...sider early addition of linezolid or daptomycin...

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

...s: Consider early use of polymyxin/colis...

...penicillin-allergic patients tolerate...

...tropenic patients who have new signs or symptoms...

...tients should receive initial oral or IV empirical...

...combination is recommended for oral empirica...

...l regimens, including levofloxacin or...

...eceiving fluoroquinolone prophylaxis should no...

Hospital re-admission or continued stay...


...Modifying A...

...difications to the initial antibiotic regime...

...d persistent fever in an otherwise stable p...

...ted clinical and/or microbiological...

...ycin or other Gram-positive coverage was s...

...who are hemodynamically unstable sho...

...ents who have been started on IV or or...

...ral switch in antibiotic regimen may be made...

...ospitalized patients who meet low-ris...

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

...ical antifungal coverage should be cons...


...Duration of Antibi...

...h clinically or microbiologically do...

...n patients with unexplained fever, it is r...

...rnatively, if an appropriate treatment course has...


...Antibiotic Prophylaxis...

...roquinolone prophylaxis should be conside...

...loxacin and ciprofloxacin have been...

...Gram-positive active agent to fluoroquinolon...

...erial prophylaxis is NOT routinely recommen...


...Empiric or Pre-...

...High Risk...

...pirical antifungal therapy and investig...

...ficient to recommend a specific empiric...

...tifungal management is acceptable as an alternativ...

...Low Risk...

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


...Antifungal Pro...

...High...

...against Candida infections is recommend...

...against invasive Aspergillus infections with...

...a mold-active agent is recommended in pat...

...pated prolonged neutropenic periods of at...

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

...Low...

...ntifungal prophylaxis is NOT recommended...


...Antiviral Prophyla...

...pes simplex virus (HSV)-seropositive patie...

...l treatment for HSV or varicella-zoster virus (...

...atory virus testing (including influenza,...

...rly influenza vaccination with ina...

...al timing of vaccination is not establi...

...za virus infection should be treated with neurami...

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

...ent of RSV in neutropenic patients wit...


...H...

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

CSFs are not generally recommended for tre...


...Central Line-Ass...

...ferential time to positivity (DTP) > 120 minutes...

...or CLABSI caused by S. aureus, P. aeruginosa, f...

...atheter removal is also recommended for t...

...nted CLABSI caused by coagulase-negati...

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

persistent bacteremia or fungemia occurr...

...her (C, III)659...

...ice hand hygiene, maximal sterile ba...


...Envir...

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

...rrier precautions should be follow...

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

...llogeneic HSCT recipients should be p...

...d dried or fresh flowers should NOT be...

...ospital work exclusion policies should b...

...2. Common Bacterial Pathogens in Neut...


Treatment

...Treatment...

...e 3. Antimicrobials Frequently Use...


...4. Indications for Addition of Gram-positive...


...al Management of Fever and Neutrope...


...ssess After 2-4 Days of Empirical Anti...


...High Risk Patient with Fever After 4 Days of Emp...