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
...finitions
Fever is defined as a single oral t...
Diagnosis and Assessment
...sis and Assessment...
...k Assessment...
...fication is a recommended starting po...
...sk for complications of severe infection should...
Risk assessment may determine type of empirical...
...-risk patients — those with anticipated prolon...
...isk patients — those with anticipated bri...
...mal risk classification may be performed using th...
...1. The MASCC Risk-Index ScoreHaving trouble view...
...OTE: The maximum value of the score is 26. Scor...
...ts and Cultu...
...tests should include a complete blood count...
...s of blood cultures are recommende...
...lumes should be limited to < 1% of to...
...ture specimens from other sites of suspecte...
...diograph is indicated for patients with respirat...
...Antibiotic Therapy...
...igh-risk patients require hospitalization...
...crobials (aminoglycosides, fluoroquinolones and...
...(or other agents active against aerobic Gram-posi...
...ifications to initial empirical therap...
...: Consider early addition of vancomycin, lin...
...r early addition of linezolid or daptomy...
...der early use of a carbapenem (B,...
...r early use of polymyxin/colistin or tigecycl...
...in-allergic patients tolerate cephalos...
...eutropenic patients who have new s...
...atients should receive initial oral or IV...
...is recommended for oral empirical...
...egimens, including levofloxacin or ciproflox...
...ing fluoroquinolone prophylaxis should not rec...
...ital re-admission or continued sta...
...ing Antibiotic Therapy...
...s to the initial antibiotic regimen sh...
...ed persistent fever in an otherwise stable pat...
...d clinical and/or microbiological infections s...
...cin or other Gram-positive coverage was st...
...s who are hemodynamically unstable should have...
...sk patients who have been started on...
...oral switch in antibiotic regimen may be...
...ed hospitalized patients who meet low-risk criteri...
...ists or recurs within 48 hours in...
...ungal coverage should be considered in...
...ion of Antibiotic Ther...
...clinically or microbiologically docum...
...ents with unexplained fever, it is recommend...
...vely, if an appropriate treatment cour...
...ntibiotic Prophy...
...olone prophylaxis should be considered...
...cin and ciprofloxacin have been evaluated mos...
...ion of a Gram-positive active agent to...
...ophylaxis is NOT routinely recommended for...
...or Pre-Emptive Antifungal Ther...
...igh Ris...
...irical antifungal therapy and investi...
...ta are insufficient to recommend a specifi...
...ntifungal management is acceptable as an alternat...
...ow Risk
...-risk patients, the risk of invasive fu...
...ungal Prophylaxis...
...igh Risk...
...hylaxis against Candida infections is recommende...
...xis against invasive Aspergillus infections with...
...d-active agent is recommended in pa...
...pated prolonged neutropenic periods o...
...prolonged period of (C, III)659...
...ow Risk...
...hylaxis is NOT recommended for patien...
...viral Prophylaxis
...es simplex virus (HSV)-seropositive patients...
...atment for HSV or varicella-zoster vi...
...rus testing (including influenza, parainflu...
...rly influenza vaccination with inactivated vaccin...
...al timing of vaccination is not established, but s...
...s infection should be treated with neuramin...
...setting of an influenza exposure or outbr...
...ine treatment of RSV in neutropeni...
...matopoietic Growth Factors (G-CSF...
...ic use of myeloid colony-stimulating facto...
...nerally recommended for treatment of establis...
...ssociated Bloodstream Infections (CLABSI)...
...fferential time to positivity (DTP)...
...CLABSI caused by S. aureus, P. aeruginosa...
...r removal is also recommended for tunnel i...
...ocumented CLABSI caused by coagulase-...
...ditis, septic thrombosis (A, II...
...cteremia or fungemia occurring > 72 hours after...
...ther (C, III)65...
...tice hand hygiene, maximal sterile b...
...nmental Precautio...
...nd hygiene is the most effective means...
...andard barrier precautions should be fo...
...patient) rooms (B, III)659...
...ic HSCT recipients should be placed...
...and dried or fresh flowers should N...
...ital work exclusion policies should be de...
...e 2. Common Bacterial Pathogens in Neutropenic...
Treatment
...atment...
Table 3. Antimicrobials Frequently Used...
Table 4. Indications for Addition of...
...l Management of Fever and Neutropenia...
...sess After 2-4 Days of Empirical Antibiotic Ther...
...e 3. High Risk Patient with Fever After...