Neutropenic fever
Definition
ANC < 500 cells/µL (severe)
OR
ANC < 1000 cells/µL (moderate) with a predicted nadir of ANC < 500 cells/µL in 48h
&
Fever ≥ 38.3˚C (101˚F) once
OR
Sustained temp ≥ 38˚C (100.4˚F) for > 1h
Pathophysiology
Nadir usually occurs 7-10d after chemo
Duration of neutropenia depends on type of cancer treatment
-Solid tumor Rx: ~<5d
-Hematologic malignancies: ~14d or longer
Leukemias, lymphomas + chemo most commonly associated with neutropenia
Common CausesDefinitive cause only found in 30%
Endogenous Flora 80%
-E Coli, Enterobacter, anaerobes
Skin
-Staph, strep
Respiratory tract
-Step pneumo, Klebsiella, Corynebacterium, Pseudomonas
Other
-C dif, Mycobacterium, Candida, Aspergillus
Presentation/Exam
Classic manifestations of infxn NOT seen
Check skin, mucosa, sinuses, indwelling cath sites CAREFULLY
-mild erythema, slight erosion in oropharynx or perianal area
-AVOID DRE
DDx
Transfusion reaction
Medication allergies and toxicities
Tumor-related fever
W/U
AVOID rectal temp
CBC with dif
Chem 10
LFTs
UA (may not show WBCs or leuk esterase given neutropenia), UCx
Sputum gram stain and Cx
BCx x 2 (20-30cc blood (adult) or 1-5cc (child); may take both samples from central venous catheter)
Cx any indwelling catheters
LP (if neuro abnl or suspicious)
Site-specific specimens
-nasopharyngeal wash in pts with UR (RSV, influenza)
Stool (if indicated)
-C dif
-O&P
-Cx
CXR
CT if necessary
-Sinuses
-Chest
-A/P
High-Risk/Special InfectionsNeutropenic Enterocolitis (Typhlitis)
Zygomycosis (see Mucormycosis)
Hepatosplenocandidiasis
-after neutropenic fever resolves and ANC has come up allowing abcess formation
--Rx ampho b
Treatment==
Even if afebrile, if si/sy of infxn, TREAT
3rd or 4th gen cephalosporin (cefepime 2g or ceftazidime 2g)
OR
Carbapenem (imipenem 500mg or meropenem 1g)
OR
Zosyn 4.5g
+/-
Aminoglycoside (gent 2-5mg/kg, amikacin)
OR
Antipseudomonal fluoroquinolone (moxi, levo, cipro)
+/-
Vancomycin 1g (alternative: quinupristin/dalfopristin, daptomycin, linezolid)
-hypotension
-Grm + Bcx
-Hx of MRSA or Bactrim resistant pneumococci
-Prior ppx with fluoroquinolone or Bactrim
-Catheter related infxn
Add Amphotericin B 0.5-1 mg/kg qd if fever >72 h or candida in esophagus, urine or stool
Add anaerobic coverage (clindamycin, flagyl) if peritonitis or abdominal symptomatology occurs
If PMNs expected to be ≤ 100/mm3 for one week, consider G-CSF/GM-CSF
-Unless pt has hx of leukemia, in which case G-CSF is generally contraindicated
- No current evidence supports antifungals or antivirals if fever alone; after 4-7 days may need to start either/both
Disposition
Low Risk patients can be safely d/c'd home using the Multinational Association for Supportive Care in Cancer (MASCC) risk index:
Patient Clinical Factor Score Severity of illness:
no symptoms or mild symptoms
moderate symptoms
5
3
No hypotension 5
No chronic obstructive pulmonary disease 4
Solid tumor or no fungal infxn 4
No dehydration 3
Outpt at onset of fever 3
Age < 60yo 2
≥21 pt = low risk for SBI
Home with close onc f/u and abx:
Cipro 500 Q8H
&
Augmentin 500 Q8H
ADMIT all other patients (majority)
Pani 6/09, DeBonis 3/10
Reference: LLSA 2009; Halfdanarson Onc Emergencies Mayo Clin Proc June 2006; EMP