Neutropenic fever
Definition: Febrile Neutropenia is defined as absolute neutrophil count (ANC) of <500 /mm3, with a single core temperature of >38.3° C (101°F) or a persistent temperature of >38° C (100.4°F), for >1 hour.
Risk factors:
The longer the duration of neutropenia, the higher the risk of developing febrile neutropenia.
Most solid tumor chemotherapy regimens have, if any, a brief (<5 day) duration of neutropenia.
The highest risk of FN is with leukemia and transplant regimens, in which neutropenia can persists for weeks.
Risk is also increased with regimens that cause mucositis (inflammation and ulceration of the oral and GI mucosa).
Diagnosis:
PE, look for mucositis, catheter sites, and of the perianal region. DRE should not be performed because of the potential risk of bacterial translocation.
Cultures of blood and urine in all patients, and stool, and sputum in symptomatic patients.
CXR should be performed in all patients.
Pt. may have received Chemo in the preceeding 7-10 days
Pt with neutropenia with UA showing bacteriuria is significant even if no WBC is seen.
Treatment:
Emergent treatment with immediate IV antibiotics to prevent life-threatening, gram-negative sepsis.
Patients should be kept in reverse isolation.
Consuming raw fruits and vegetables had been discouraged in the past but more recently has been found not to lead to excessive risk.
Antimicrobial treatment:
Immediate, empiric IV ABx with coverage of GPC and GNB (including Pseudomonas aeruginosa) must be included.
Empiric coverage of MRSA with vancomycin is not recommended unless patients are unstable, have active, oral mucositis, have evidence of a catheter-related infection, or had a recent infection with MRSA.
Antimicrobials should be modified according to the source of infection if one is identified (i.e., Clostridium difficile, MRSA, anaerobes, P. carinii).
Persistent fever does not warrant an empiric change in antibacterial therapy.
Gram-negative coverage should continue until ANC is >500/mm3.
Low-risk patients (afebrile for 24 hours after ABx, negative culture results, and expected duration of myelosuppression for <1 week) can be treated as OP with PO Abx such a fluoroquinolone, amoxicillin/clavulanic acid, or TMP-SMX.
Cefepime, ceftazidime, imipenem, or meropenem +/- aminoglycoside, +/- vancomycin.
Antifungal; fluconazole.
Remove vascular access devices
White cell growth factors (G-CSF, GM-CSF)
These may reduce the duration of hospitalization for FN, but do not improve survival.
G-CSF is the most commonly used agent, given subcutaneously in doses of 5 mg/kg/day.
CSFs should not be given <24 hours after chemotherapy or during radiation because of the potential for increased myelosuppression.
Prophylactic G-CSF is used in the curative setting to prevent FN when the risk is >15% and to reduce the duration of neutropenia to prevent chemotherapy delays.
Use G-CSF for FN prophylaxis in the palliative setting is controversial since chemotherapy regimens with high rates of FN are usually not appropriate.
Neupogen (Filgrastim) is given after chemotherapy to build up WBC count for the next chemotherapy.