Definitions According to the Infectious Diseases Society of America's Current Recommendations1
Fever: Single oral temperature ≥38.3°C (≥101°F) or a temperature ≥38.0°C (≥100.4°F) for 1 hour or longer
Neutropenia: Absolute neutrophil count (ANC) of <500 cells/mm3, or a count expected to decrease to <500 cells/mm3 during the next 48 hours
In patients with fever and neutropenia:
10–20%: Microbiologically documented infection (most commonly bacteremia)
20–30%: Clinically documented infection (eg, cellulitis, pneumonia, typhlitis)
50–70%: No clinically or microbiologically documented infection
Bacteria are the most commonly documented etiology
Gram-positive bacteria predominate in recent series; however, the frequency of Gram-negative bacteria is increasing
Gram-negative bacteremia may be associated with faster clinical deterioration and death as compared to Gram-positive bacteremia. Hence empirical treatment is targeted to cover Gram-negative pathogens, particularly Pseudomonas aeruginosa
Candida and Aspergillus species are the most common causes of invasive fungal infections in neutropenic patients. They are uncommon early or during short episodes of neutropenia but increase in frequency with longer duration of neutropenia
Factors contributing to immune compromise of an individual patient:
Corticosteroids, fludarabine, and alemtuzumab (Campath-1H) produce severe defects in cellular immunity
Myeloma and CLL are accompanied by defects in humoral immunity
Patients without a spleen are at risk of overwhelming sepsis caused by encapsulated bacteria, mainly Streptococcus pneumoniae
Obstruction (biliary obstruction, ureteral obstruction, bronchial obstruction) facilitates local infection (cholangitis, pyelonephritis, postobstructive pneumonia)
Intravascular devices, drainage tubes, or stents may become colonized and lead to local infection, bacteremia, or fungemia
Expeditious evaluation is mandatory, with special attention to skin, mouth, perianal region, and lungs
Cultures of blood✫, urine, and sputum should be obtained in all patients
In case of diarrhea, stool culture with a test to rule out Clostridium difficile (PCR is most sensitive) should be obtained
In case of signs or symptoms of upper respiratory tract infection, a nasopharyngeal wash to screen for viruses should be obtained
CBC with differential count, chemistry panel, and chest radiograph should be obtained at baseline
Antimicrobial treatment should be instituted without delay (for dosage, route of administration, dose adjustment for renal and hepatic impairment of specific agents, see Appendix I)
High-risk patients have ANC <100 cells/mm3 and expected duration >7 days, and/or significant comorbidities (hypotension, pneumonia, new-onset abdominal pain, or neurologic changes). They should be admitted and treated with IV antibiotics. Low-risk patients have anticipated brief neutropenia periods and no or few comorbidities, and may be considered for oral or outpatient therapy, provided they have good access to a health care system
A flow diagram with suggested antibiotic therapy for inpatients with fever and neutropenia is presented in Figures 47-1 We recommend a systematic approach in which specific questions are answered in order:
In a clinically stable patient:
In a clinically stable patient who does not need vancomycin (uncomplicated fever and neutropenia), intravenous monotherapy with an antipseudomonal β-lactam (cefepime, piperacillin-tazobactam, imipenem, or meropenem)✫ is recommended. Combination therapy with ...
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