Febrile neutropenia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

Fever in a neutropenic patients is defined as one oral temperature of >38.3°C (101°F) or a temperature of >38.0°C (100.4°F) for >1 hour. Neutropenia is defined as an absolute neutrophil count (ANC) <1500 cells/microL. Severe neutropenia is defined when the ANC <500 cells/microL, or an ANC that is expected to decrease to <500 cells/microL over the next 48 hours. Clinically significant infections usually occurs with severe neutropenia

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Life threatening cause 1
• Life threatening cause 2
• Life threatening cause 3

Common Causes

• Common cause 1
• Common cause 2
• Common cause 3
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Management

Shown below is an algorithm summarizing the approach to febrile neutropenia.

Confirm fever and neutropenia: ❑ Single oral temperature ≥38.3°c (1010.4°F), OR ❑ Temperature ≥38°c (101°F) sustained for over one hour AND ❑ Absolute neutrophil count (ANC) <500 cells/mm3, OR ❑ ANC that is expected to decrease to <500 cells/mm3 in the next 48 hours

Obtain a detailed history: ❑ New site specific onset ❑ Exposure to infections ❑ Prior documented infections or pathogen colonization ❑ Non infectious causes of fever (example: administration of blood products) ❑ Recent surgical procedures ❑ Current antibiotic prophylaxis

Examine the patient: ❑ Site of previous procedures (entry and exit sites of catheters, bone marrow aspiration site) ❑ Oropharynx (perioduntum) ❑ Alimentary tract ❑ Lungs ❑ Perineum

Order lab tests and cultures: Labs every 3 days during the course of antibiotics: ❑ CBC ❑ Electrolytes ❑ Serum creatinine ❑ BUN Labs weekly during the course of antibiotics ❑ Transaminases Cultures: ❑ Blood culture (repeat every day for two days) Additional tests (not routine) ❑ Stool test for clostridium difficile toxin (if diarrhea is present) ❑ Urine culture ( if there are UTI symptoms, urinary cath, abnormal urinalysis) ❑ Skin aspiration or biopsy (suspicion of an infected lesion) ❑ Respiratory specimen ❑ CXR ❑ CSF analysis

DO A RISK ASSESSMENT

LOW RISK ❑ MASCC score* ≥21, OR ❑ Anticipated brief neutropenia (≤ 7 days), OR ❑ Clinically stable patient, OR ❑ No comorbidities

HIGH RISK ❑ MASCC score* <21, OR ❑ Anticipated prolonged neutropenia (> 7 days) AND profound neutropenia (ANC≤100 cells mm3), OR ❑ Presence of comorbidities

Outpatient oral antibiotics ❑ Ability to tolerate oral medications ❑ Availabilty of telephone, transportation to hospital, caregiver

Inpatient IV antibiotics ❑ Inability to tolerate oral medications ❑ Unavailabilty of telephone, transportation to hospital, caregiver ❑ Identified infection necessitating IV antibiotics

Inpatient IV antibiotics

Administer oral antibiotics: ❑ ciprofloxacin + amoxicillin/clavulanate Observe and discharge: ❑ Observe for 4 hours following the initial dose of antibiotics and discharge for outpatient treatment after making sure the patient is stable and tolerating the treatment

Administer IV monotherapy with an antipseudomonal: ❑ Cefepime, OR ❑ Piperacillin/tazobactam, OR ❑ Carbapenem

References

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