A 65-year-old patient is admitted unwell after the first cycle of cytotoxic chemotherapy. The full blood count reveals: Hb 78 g/l; WCC 0.2 × 109/l; neutrophils 0.01 × 109/l; platelets 48 × 109/l. Vital signs: temperature 38.6 °C; pulse 120 bpm; blood pressure 150/84 mmHg. The central venous catheter (CVC) exit site is inflamed with a purulent discharge.
What is febrile neutropenia?
How is it evaluated?
What is the treatment?
What is febrile neutropenia?
Febrile neutropenia is defined as single temperature reading above 38.5 °C while having an absolute neutrophil count (ANC) 0.5 × 109/l. Bodey et al.'s seminal work first described the association between ANC and pyogenic infection and also identified that Gram-negative rod bacteraemia due to Pseudomonas aeruginosa is associated with a mortality rate of >50% within 48 hours.1 Despite relatively high rates of neutropenia during standard dose chemotherapy regimens, rates of febrile neutropenia and mortality are now relatively low for most standard chemotherapy regimens (Table 4.1). The median time of onset for the first febrile neutropenic episode is day 12 of a cytotoxic cycle.2 This correlates with the nadir of the neutrophil count and with the integumental damage to the intestinal mucosal epithelium. The most common sources of infection, in decreasing order are: gastrointestinal tract (especially the periodontium and oropharynx), bloodstream, skin (predominantly from indwelling CVCs), lower respiratory tract and the urinary tract.3 There has been a shift in the causative organisms for bacteraemia over the past few decades from Gram-negative rods such as Escherichia coli, Klebsiella pneumoniae and P. aeruginosa to aerobic, Gram-positive cocci such as Staphylococcus, Streptococcus and Enterococcus.4
Table 4.1Incidence of febrile neutropenia and other complications, and mortality5 |Favorite Table|Download (.pdf) Table 4.1 Incidence of febrile neutropenia and other complications, and mortality5
|Leukopenia WHO grade 4 ||2–28% |
|Febrile neutropenia ||10–57% |
|Infections WHO grade 3 or 4 ||Up to 16% |
|Death in febrile neutropenia ||0–7% |
The management of patients with febrile neutropenia includes a rapid and meticulous clinical evaluation to identify a clinical focus of infection and a causative pathogen, administration of broad-spectrum antibacterial therapy, and a strategy to monitor the patient for medical complications. Given that immunocompromised hosts rarely mount an adequate inflammatory response to infection, the classic signs and symptoms of infection may be minimal or absent. In particular, it is useful to enquire whether the patient has been administered any blood products in the past 24 hours and whether rigors are associated with the flushing of a central venous line. Physical examination should include oropharynx, sinuses, skin, fundi and perineum (defer rectal examination until antibiotics have been started). In ...