Febrile Neutropenia

What are the factors that increase the risk of infection in patients with Solid tumors?

• Neutropenia

• Disruption of anatomic barriers

• Obstruction due to primary or metastatic tumor

• Procedure and devices

• Miscellaneous factors

Neutropenia definition

Absolute neutrophil count (ANC) of 500 or ANC that is expected to decrease to 500 during the next 48 houts

Profound neutropenia def

Occasionally used to decscribe neutropenia in which the ANC is 100

Functional neutropenia

Normal neutrophil count but hematologic malignancy results in qualitative defects of circulating neutrophils

Fever def

• A single oral temperature measurement of >38.3 degrees C (101 F) or a temp of >38 C (100.4) F sustained over a 1 hour period

• Axillary temp discouraged

• Avoid rectal temp to prevent colonizing gut organisms from entering

What are the causes of fever in neutropenic patients, both microbiologically and non-microbiologically?

Decreased Production

Peripheral Destruction

Peripheral Pooling

Decreased Neutropenia Production

Peripheral Destruction

Peripheral Pooling Causes

• Overwhelming bacterial infection

• Hemodialysis

• Cardiopulmonary bypass

What is the duration of neutropenia cut-off to determine high risk vs low-risk patients?

High risk	Low Risk
Anticipated prolonged (>7 days duration) and profound neutropenia and/or Significant comorbid conditions: hypotension, pneumonia, new-onset abdominal pain, or neurologic changes	Anticipated bried (7 or less days) neutropenic periods or No or few comorbiditieds

What are the comorbidities/conditions that classify patients as high risk.

Presence of any active uncontrolled comorbid medical problems, including:

• Signs of severe sepsis or septic shock

• Oral or gastrointestinal mucositis that interferes with swallowing or causes severe diarrhea

• Gastrointestinal symptoms, including abdominal pain, nausea and vomiting, or diarrhea

• Intravascular catheter infection, especially catheter tunnel infection

• New pulmonary infiltrate or hypoxemia

• Underlying chronic lung disease

• Complex infection at the time of presentation

empiric treatment regimen for a high and low-risk febrile neutropenia patient.

Fluoroquinolones good

When should you consider antifungals in neutropenic patients? Which ones should be considered?

For high risk patients only; add after 4-7 days if continued fever

• AmpB and caspofungin are options

How do you determine duration of treatment in febrile neutropenic patients?

• In clinically or microbiologically documented infections, the duration of therapy is dictated by the particular organism and site

• For others, continue abx for at least the duration of neutropenia or longer if clinically necessary

When should you consider antimicrobial prophylaxis? Design an empiric prophylaxis regimen for these patients.

• Fluoroquinolone prophylaxis should be considered for high-risk patients with expected durations of prolonged and profound neutropenia (ANC <100 cells/mm³ for > 7 days)

  • Levo and Cipro considered mostly equivalent,

  • But Levo is preferred in situations with increased risk for oral mucositis-related invasive viridans group streptococcal infection

  • FQ resistance should be monitored

• Prophylaxis is not routinely recommended for low-risk patients who are anticipated to remain neutropenic for > 7 days

is Addition of a gram-positive active agent to fluoroquinolone prophylaxis reccomeended?

generally not recommended