Most common in hematologic malignancies, however those with solid tumors are also at risk, especially after first round of chemotherapy
Mortality rates drop the faster big gun antibiotics are given. Don't be skimpy and give Unasyn. Use the big bad boys like single agent Pip/Tazo (4.5 grams, not 3.375), Cefipime, etc. Have a low threshold for adding Vancomycin.
Febrile neutropenia (FN) is among the most serious clinical complications in patients with cancer who are undergoing chemotherapy. Patients with neutropenia, or low neutrophil counts, are predisposed to serious and life-threatening infections because of their immune system’s impaired ability to mount inflammatory responses to bacteria, fungi, and yeast.
Patients who are low risk may be either admitted with IV antibiotics followed by transition to oral outpatient therapy, or discharged from the ED with oral antibiotics.
Zosyn OR Cefepime OR Ceftazadime OR Carbapenem — Though pseudomonal infection is actually uncommon, bacteremia from it is quite concerning; therefore, your AB regimen (even if single) should always include coverage against it. Add Vancomycin if concerned for gram positive bug— Ie: prior MRSA infections, cellulitis, mucositis, already on gram negative prophylaxis.
The Infectious Disease Society of America (IDSA) defines fever in neutropenic patients
as a single oral temperature of greater than 38.0C, or 100.4F, for greater than
1 hour.2 Although rectal measurement most accurately reflects the core body temperature, oral or axillary temperature measurements are recommended because of the
theoretical risk of bacterial translocation during the procedure of inserting the thermometer probe into the anus.
There are a number of scoring systems used to assess a patient’s risk of bacteremia and morbidity/mortality. None of them are universally agreed upon.
To outline an approach to the febrile oncologic patient.
FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.
Neutropenia is one of the two common instances when a rectal temperature is wrong; the other is thrombocytopenic patients. Oral temperature is adequate; make sure they don’t have oral mucositis that can falsely increase the reading in the patient’s thermometer and your head at the same time.
Scores such as the Multinational Association for Supportive Care in Cancer (MASCC) (solid and hematologic malignancies) and Clinical Index of Stable Febrile Neutropenia (CISNE) (solid malignancies) can assist in patient disposition
Identifies febrile neutropenia patients at low risk of serious complications.
Identifies patients at low risk for poor outcome with febrile neutropenia..
Identify low risk patients and send them home with PO antibiotics and close oncology follow-up in conjunction with your oncologist.
AVOID rectal temp or digital rectal exam.