Chapter 36 • Risk assessment is an important tool for evaluation and treatment in patients with cancer who have fever and neutropenia. Patients who are expected to have neutropenia lasting more than 7 days, including those undergoing allogeneic stem cell transplantation or therapy for acute leukemia, are considered to be at high risk for infectious complications. Most patients with solid tumors will have neutropenia lasting fewer than 7 days and are considered to be at low risk. • Other risk factors for infection in patients with cancer, beside chemotherapy- and disease-related neutropenia, are the presence of indwelling catheters, comorbid medical conditions such as diabetes or chronic obstructive pulmonary disease, recent surgery, malnutrition, and cellular and humoral immune defects from an underlying tumor and its treatment. • Fever during neutropenia necessitates immediate evaluation, assessment of risk as high or low, appropriate cultures, and prompt institution of empirical broad-spectrum antibacterial therapy with a defined regimen that covers Pseudomonas aeruginosa and enteric gram-negative organisms, as well as common institutional pathogens. Gram-positive active agents are not a standard component of the empirical treatment regimen for fever and neutropenia. • Antibiotic prophylaxis with levofloxacin has been shown to decrease fever and infection in high-risk patients with acute leukemia or those undergoing stem cell transplantation, with neutropenia (<1000 neutrophils/mm3) lasting more than 7 days, although no morality benefit has been consistently shown. • Posaconazole prophylaxis reduces the incidence of invasive fungal infections and mortality in patients undergoing induction for acute leukemia and reduces fungal infections in patients treated for higher grade graft-versus-host disease. Voriconazole has been shown to be equivalent to fluconazole for prevention of fungal infections in allogeneic stem cell transplant recipients. • Newer agents used to treat a variety of lymphoproliferative disorders (e.g., alemtuzumab and purine analogs) result in prolonged suppression of cellular immunity and predispose persons to certain infections; patients receiving these agents may benefit from prophylaxis against opportunistic infections. • An epidemic strain of Clostridium difficile has emerged as a major cause of morbidity and mortality in many centers, and fluoroquinolone use is a risk factor. Metronidazole is recommended for mild disease, but oral vancomycin should be given for more severe symptoms of C. difficile infection.
Infection in the Patient with Cancer
Summary of Key Points
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Infection in the Patient with Cancer
