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Neutropenic Fever

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Topic updated on 11/04/16 10:57am

Snapshot
File:Neutrophils.jpg
  • A 68-year-old female on outpatient chemotherapy for non-Hodgkin's lymphoma presents to the Emergency Room with a temperature of 38.4 degrees Celsius. Laboratory tests reveal an absolute neutrophil count of 372/mm^3
Introduction
  • Fever in neutropenic patient > 38.3 degrees Celsius on single oral temp or temp > 38.0 degrees Celsius > 1 hour
    • neutropenia is an absolute neutrophil count (ANC) <500/mm^3
  • Causes include
    • bone marrow failure or invasion
    • hypersplenism
    • systemic lupus erythematosus
    • AIDS
  • Risk factors
    • cancer patient on chemotherapy
    • catheters
    • skin breakdown
    • obstruction (biliary, GI, lymphatic, urinary tract)
Classification
  • Risk stratification
    • low risk
      • solid tumor treated as outpatient
      • neutropenia <10 days
      • no major comorbidity
    • high risk
      • high-dose chemotherapy
      • hematologic malignancy
Presentation
  • Symptoms
    • fever may be only manifestation of infection
Evaluation
  • Labs
    • pan cultures
    • CBC
    • metabolic panel 
  • Radiographs
    • CXR
  • CT scan
    • if abscess suspected
Treatment
  • Broad spectrum antibiotics with antipseudomonal activity
    • PO ciprofloxacin + augmentin
      • indicated in low risk patients
    • Ceftazidimecefepimecarbapenem
      • indicated as monotherapy 
    • aminoglycoside + antipseudomonal beta-lactam 
      • indicated as 2 -drug therapy
    • vancomycin 
      • indicated for high-risk patients or persistent fever > 3-5 days
  • Antifungals
    • indicated if fever > 3 days
  • Colony stimulating factors
    • routine use not indicated


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