Neutropenic Fever
Susan Harwell
Ashley Tyler
Christopher Trabue
INTRODUCTION
With the advent of cytotoxic chemotherapy for both acute leukemia and solid organ tumors over the past half century, the landscape on oncologic medicine has dramatically changed. However, with improved survival rates and the prospect of cure also came the potential for overwhelming and sometimes fatal infection in the context of neutropenia. Guidelines for both the prevention and management of such infections have been developed and serve to provide a framework for the evaluation and treatment of these patients.
BACKGROUND/EPIDEMIOLOGY
I. DEFINITIONS
a. Fever is defined as temperature ≥100.5°F.
b. Neutropenia is defined as an absolute neutrophil count (ANC) ≤500 cells/mL or trend toward neutropenia.
II. MICROBIOLOGY
a. Bacteriology has fluctuated wildly over the past five decades.
b. Although gram-positive bacteria, including Staphylococcus aureus and coagulase-negative staphylococci, historically caused the majority of bloodstream infections in the 1980s and 1990s, gram-negative pathogens including multidrug-resistant gram-negative bacilli/extended spectrum beta-lactamase (ESBL)-producing gram-negative bacilli have emerged over the last decade.
c. Common gram-positive pathogens in neutropenic patients
i. Coagulase-negative staphylococci, including Staphylococcus lugdunensis
ii. S. aureus, including methicillin-resistant Staphylococcus aureus (MRSA)
iii. Enterococcus species, including vancomycin-resistant Enterococcus (VRE)
iv. Viridans group streptococci
v. Streptococcus pneumoniae
vi. Streptococcus pyogenes
d. Common gram-negative pathogens in neutropenic patients
i. Escherichia coli
ii. Klebsiella pneumoniae
iii. Enterobacter cloacae
iv. Pseudomonas aeruginosa
v. Acinetobacter species
vi. Stenotrophomonas maltophilia
e. Fungal pathogens
i. Aspergillus species remain the most common cause of invasive fungal infection in neutropenic cancer patients.
ii. Other common fungal pathogens in neutropenic cancer patients
1. Candida species (including Candida albicans and non-albicans species such as Candida krusei, Candida glabrata, and Candida tropicalis)
2. Fusarium species
3. Agents of mucormycosis
PRINCIPLES OF THERAPY
I. FEVER DURING NEUTROPENIA IS ALWAYS CONSIDERED A MEDICAL EMERGENCY.
II. FEVER DURING NEUTROPENIA IS ALWAYS CONSIDERED AS DUE TO INFECTION, UNTIL PROVEN OTHERWISE.
III. NEUTROPENIC HOSTS OFTEN DO NOT DISPLAY SIGNS OR SYMPTOMS OF INFECTION.
IV. NEUTROPENIC HOSTS ARE UNIQUELY SUSCEPTIBLE TO ORDINARILY MUNDANE OR TRIVIAL INFECTIONS.
ASSESSMENT OF RISK
I. ALL CANCER PATIENTS WITH NEUTROPENIC FEVER SHOULD UNDERGO RISK ASSESSMENT TO DETERMINE LEVEL OF CARE, VENUE OF TREATMENT, EXTENT OF DIAGNOSTIC EVALUATION, AND SELECTION AND ROUTE OF EMPIRICAL ANTIBIOTIC THERAPY.
II. THE MULTINATIONAL ASSOCIATION FOR SUPPORTIVE CARE IN CANCER (MASCC) SCORING SYSTEM IS A USEFUL TOOL FOR DEFINING RISK IN SUCH PATIENTS (TABLE 69-1).
a. MASCC score of <21 → High risk
b. MASCC score of ≥21 → Low risk
III. HIGH-RISK PATIENTS (MASCC SCORE <21) INCLUDE THOSE WITH:
a. Anticipated prolonged (>7 days duration) neutropenia
b. Profound neutropenia (ANC ≤100 cells/mm3) following cytotoxic chemotherapy
c. Significant medical comorbid conditions, including
i. Hypotension
ii. Pneumonia
iii. New-onset abdominal pain
iv. Neurologic changes
Table 69-1 Multinational Association for Supportive Care in Cancer (MASCC) | ||||||||||||||||||||
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