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
...as a single oral temperature measu...
Diagnosis and Assessment
...osis and Assessment...
...Assessment...
...stratification is a recommended starting point fo...
...risk for complications of severe infecti...
...assessment may determine type of empir...
...patients — those with anticipated prolonged (>...
...ients — those with anticipated brief (â‰...
...mal risk classification may be performed using...
...MASCC Risk-Index ScoreHaving trouble viewing tabl...
...aximum value of the score is 26. Scores below...
Tests and Cultures
...ts should include a complete blood count...
...sets of blood cultures are recommended:...
...volumes should be limited to < 1% of total blo...
...ture specimens from other sites of suspec...
...ograph is indicated for patients with respirat...
...mpiric Antibiotic Ther...
...ts require hospitalization for IV empiric...
...crobials (aminoglycosides, fluoroquinolones and/...
...n (or other agents active against ae...
...cations to initial empirical therapy ma...
...sider early addition of vancomycin, linezolid or...
...er early addition of linezolid or daptomycin (B, I...
...er early use of a carbapenem (B, III)659...
...er early use of polymyxin/colistin or...
...in-allergic patients tolerate cephalospori...
...tropenic patients who have new signs or symptom...
...patients should receive initial oral...
...mbination is recommended for oral empirical trea...
...egimens, including levofloxacin or...
Patients receiving fluoroquinolone prophylaxis s...
...tal re-admission or continued stay in the...
Modifying Antibiotic...
...ications to the initial antibiotic regimen shoul...
...persistent fever in an otherwise stable patien...
...linical and/or microbiological infections...
...or other Gram-positive coverage was starte...
...ho are hemodynamically unstable should have th...
...patients who have been started on I...
...IV-to-oral switch in antibiotic regimen may be...
...elected hospitalized patients who meet lo...
...fever persists or recurs within 48 hours i...
...fungal coverage should be considered in high-risk...
...tion of Antibiotic Therapy...
...th clinically or microbiologically documen...
...patients with unexplained fever, it is recommende...
...ely, if an appropriate treatment course...
...biotic Prophylaxis
...one prophylaxis should be considered for high...
...xacin and ciprofloxacin have been...
...n of a Gram-positive active agent to fluor...
...prophylaxis is NOT routinely recommended for low-r...
...ric or Pre-Emptive Antifungal T...
High Ris...
...rical antifungal therapy and investig...
...sufficient to recommend a specific empir...
...tifungal management is acceptable as an altern...
Low Ris...
...risk patients, the risk of invasive fung...
...ntifungal Prophylaxis
...gh Risk
...rophylaxis against Candida infections is recomme...
...gainst invasive Aspergillus infections with...
...old-active agent is recommended in pa...
...d prolonged neutropenic periods of at least...
...nged period of (C, III)...
...w Risk
...ylaxis is NOT recommended for patients in whom...
...iviral Prophylaxi...
...virus (HSV)-seropositive patients un...
...l treatment for HSV or varicella-zoster virus...
Respiratory virus testing (including...
...a vaccination with inactivated vaccine is...
...ptimal timing of vaccination is not...
...infection should be treated with neur...
...of an influenza exposure or outbreak, neutrop...
...eatment of RSV in neutropenic patients wi...
...poietic Growth Factors (G-CSF or GM-...
...rophylactic use of myeloid colony-stimulating...
...are not generally recommended for...
...e-Associated Bloodstream Infections...
Differential time to positivity (DTP)...
...r CLABSI caused by S. aureus, P. aerugino...
...val is also recommended for tunnel infec...
...LABSI caused by coagulase-negative staphyloc...
...s, septic thrombosis (A, III)659...
...t bacteremia or fungemia occurring...
for other (C,...
...and hygiene, maximal sterile barrier...
...nmental Precautions...
...d hygiene is the most effective means of...
...dard barrier precautions should be follo...
...e-patient) rooms (B, III)659...
...eneic HSCT recipients should be placed in r...
...lants and dried or fresh flowers should NOT be...
...tal work exclusion policies should be d...
...Common Bacterial Pathogens in Neutropenic Pati...
Treatment
Treatment
...e 3. Antimicrobials Frequently UsedHaving tr...
...ndications for Addition of Gram-posi...
Figure 1. Initial Management of Fever and...
...sess After 2-4 Days of Empirical Antibiot...
...High Risk Patient with Fever After...