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.