image by: Rhoda Baer - NIH

HWN Suggests

Neutropenic Fever Syndrome

The management’s holy grail is antibiotics, but with such diverse and elite targets, where do you shoot? Let us try and oversimplify this: If the bugs are coming from our gut, they better be gram-negative rods (Pseudomonas aeruginosa!) That was so very true back in the day. Now, with the introduction to long-term indwelling central venous catheters, the empiric antibiotics to cover P. aeruginosa, and other gram negatives (Ciprofloxacin)– Staphylococcus epidermidis is winning the race. The gram-negatives are catching up; 60:40 is the score currently.

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Featured

 Febrile Neutropenia in the ED

Most common in hematologic malignancies, however those with solid tumors are also at risk, especially after first round of chemotherapy

 Neutropenic Fever-Pearls and Pitfalls

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.

 The Relevance of Febrile Neutropenia in Oncology

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.

Articles of Interest

Emergency Oncology Updates: Can patients with neutropenic fever be discharged?

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.

Neutropenic Fever

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.

Neutropenic Fever

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.

Neutropenic Fever- Peds

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.

Oncologic Emergencies Part 1

To outline an approach to the febrile oncologic patient.

Paucis Verbis: Neutropenic fever in cancer patients

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

Resources

10 Best Papers of 2021, Peripartum Cardiomyopathy, Crashing Asthmatic, Febrile Neutropenia, Anaphylaxis update

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

Clinical Index of Stable Febrile Neutropenia (CISNE)

Identifies febrile neutropenia patients at low risk of serious complications.

MASCC Risk Index for Febrile Neutropenia

Identifies patients at low risk for poor outcome with febrile neutropenia..

Rebel EM

Identify low risk patients and send them home with PO antibiotics and close oncology follow-up in conjunction with your oncologist.

WikEM

AVOID rectal temp or digital rectal exam.