Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy
Triage to Initial Empirical Antibiotic Therapy
Figure 1. Triage to Initial Empirical Antibacterial Therapy
Figure 1. Triage to Initial Empirical Antibacterial Therapy—Footnotes
a Fever is defined as a single oral temperature of ≥38.3°C (101°F), or a temperature of ≥38.0°C (100.4°F) sustained over a one-hour period.
b In the absence of an alternative explanation, clinicians should assume that fever in a patient with neutropenia from cancer therapy is the result of an infection. The initial diagnostic approach should maximize the chances of establishing clinical and microbiologic diagnoses that may affect antibacterial choice and prognosis. A systematic evaluation should include:
- Complete history and physical examination to identify infectious foci.
- Complete blood count with leukocyte differential count, hemoglobin and platelet count; serum electrolytes; serum creatinine and blood urea nitrogen; serum lactate; and liver function tests including total bilirubin, alkaline phosphatase, and transaminases.
- At least two sets of blood cultures from different anatomic sites, including a peripheral site as well as at least one line lumen of a central venous catheter if present, although the Expert Panel recognizes that that some centers may modify this practice and use only peripheral cultures, given the potential for false positive results with blood cultures from the line lumen of a central venous catheter.
- Cultures from other sites such as urine, lower respiratory tract, CSF, stool, or wounds, as clinically indicated.
- Chest imaging study for patients with signs and/or symptoms of lower respiratory tract infection, and consider chest imaging for other patients.
c Administration of empirical antibiotics:
- Assessment should occur soon (e.g., within 15 minutes) after triage for patients presenting with febrile neutropenia (FN) within 6 weeks of receiving chemotherapy. This assessment is intended to be a sensitive test with low specificity, emphasizing inclusivity rather than exclusivity.
- High-risk patients require hospitalization for IV empirical antibiotic therapy.
- The first dose of empirical therapy should be administered within one hour after triage from initial presentation. In addition, the following recommendations from the 2010 IDSA guidelines are endorsed:
- Patients who are seen in clinic or the ED for FN and whose degree of risk has not yet been determined to be high or low within one hour should receive an initial IV dose of therapy while undergoing evaluation.
- Monotherapy with an antipseudomonal β-lactam agent, such as cefepime, a carbapenem (meropenem or imipenem-cilastatin), or piperacillin-tazobactam, is recommended. Other antimicrobials (aminoglycosides, fluoroquinolones, and/or vancomycin) may be added to the initial regimen for management of complications (e.g., hypotension and pneumonia) or if antimicrobial resistance is suspected or proven.
- Vancomycin (or other agents active against microaerophilic Gram-positive cocci) is not recommended as a standard part of the initial antibiotic regimen for fever and neutropenia. These agents should be considered for specific clinical indications, including suspected catheter-related infection, skin or soft-tissue infection, pneumonia, or hemodynamic instability.
- Modifications to initial empirical therapy may be considered for patients at risk for infection with the following antibiotic-resistant organisms, particularly if the patient’s condition is unstable or if the patient has positive blood culture results suspicious for resistant bacteria. These include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL)–producing Gram-negative bacteria, and Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria. Risk factors include previous infection or colonization with the organism and treatment in a hospital with high rates of endemicity.
- MRSA: Consider early addition of vancomycin, linezolid, or daptomycin.
- VRE: Consider early addition of linezolid or daptomycin.
- ESBLs: Consider early use of a carbapenem.
- KPCs: Consider early use of polymyxin-colistin or tigecycline, or a newer β-lactam with activity against resistant gram negative organisms as a less toxic and potentially more effective alternative.
Identification of Candidates for Outpatient Management
Figure 2. Identification of Candidates for Outpatient Managementa
Figure 2. Identification of Candidates for Outpatient Management—Footnotes
a Clinical judgment should be used when selecting candidates for outpatient management.
( IC , L , S )- Residence ≤1 hour or ≤30 miles (48 km) from clinic or hospital
- Patient’s primary care physician or oncologist agrees to outpatient management
- Able to comply with logistic requirements, including frequent clinic visits
- Family member or caregiver at home 24 hours a day
- Access to a telephone and transportation 24 hours a day
- No history of noncompliance with treatment protocols
- The following additional measures are recommended:
- Frequent evaluation for ≥3 days in clinic or at home
- Daily or frequent telephone contact to verify (by home thermometry) that fever resolves
- Monitoring of ANC and platelet count for myeloid reconstitution
- Frequent return visits to clinic.
f In patients with fever and neutropenia who are appropriate candidates for outpatient management, the first dose of empirical therapy should be administered in the clinic, emergency room, or hospital department after fever has been documented and pretreatment blood samples drawn.
( IC , L , M )Recommendation Grading
Overview
Title
Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy
Authoring Organizations
Publication Month/Year
February 20, 2018
Last Updated Month/Year
October 2, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To provide an updated joint ASCO/Infectious Diseases Society of American (IDSA) guideline on outpatient management of fever and neutropenia in patients with cancer.
Target Patient Population
Patients with cancer who require treatment of fever and neutropenia.
Target Provider Population
Oncologists, infectious disease specialists, emergency medicine physicians, nurses
PICO Questions
Which patients with fever and neutropenia can be treated as outpatients, and what are the appropriate interventions for these patients?
What is the recommended initial diagnostic approach for patients with fever who are seeking emergency medical care within 6 weeks of receiving chemotherapy?
Which patients with FN are at low risk of medical complications and are, therefore, candidates for outpatient management?
What psychosocial and logistic recommendations must be met for patients to be eligible for outpatient management?
Should patients with FN who are appropriate candidates for outpatient management receive their initial dose(s) of empirical antimicrobial(s) in the hospital or clinic and be observed, or can they be discharged immediately after evaluation?
What antimicrobials are recommended for outpatient empirical therapy in patients with FN?
If low-risk outpatients with FN do not defervesce after 2 to 3 days of an initial, empirical, broad-spectrum antibiotic regimen, should they be considered for hospitalization or continue to be treated on an outpatient basis?
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D064147 - Febrile Neutropenia
Keywords
cancer, neutropenia, neutropenic fever, Fever and Neutropenia
Source Citation
DOI: 10.1200/JCO.2017.77.6211 Journal of Clinical Oncology 36, no. 14 (May 10, 2018) 1443-1453.