Febrile Neutropenia

Dr. Ahmed MjaliHematology /

Oncology

Considered primary cause of mortality in 36% of cancer patients

Considered secondary cause of mortality in 68% of cancer patients.

It is the most common cause of mortality & morbidity in cancer patients.

IntroductionNeutrophils are the most abundant

type of WBC in mammals.

They are the first responders of inflammatory cells after bacterial infection

Short life span of 4-5 days in circulation

What's febrile neutropenia ?Fever as single oral temperature

more than 38.3 C or temperature greater than 38 for 1 hour or more.

Neutrophil count less than 500 cells/ µl.

Common complication of chemotherapy.

work up

History & physical examinationDifferential CBC RFT , LFT , Electrolytes & uric acid At least 2 sets of blood cultures &

culture specimens from sites of suspected infection.

Sputum cultureUrine analysisCXR is indicated for patients with

respiratory signs or symptoms

Risk stratification

high-risk patients Prolonged neutropenia :>7 days

durationProfound Neutropenia (absolute

Neutrophil count [ANC] <100 cells/mm3)

Medical co-morbid conditions, including hypotension ,pneumonia, new-onset abdominal pain, or neurologic changes.

Such patients should be initially admitted to the hospital for empirical therapy.

Low-risk patients Short duration neutropenia (<7

days duration) No or few comorbidities are

candidates for oral empirical therapyStable renal and hepatic function

What MSCC (multinational association for supportive care ) score?

Low risk <21 High risk >21

Treatment

Low risk treatment1.Ciprofloxacin plus amoxicillin-

clavulanate in combination is recommended.

2. Levofloxacin

Hospital admission is required for persistent fever or signs and symptoms of infection.

High risk treatment Always cover pseudomonas Meropenem CefepemeMonotherapy Imepenem Piperacilin-

tazopactam Add Aminoglycoside if : Sever septic shock Evidence of P. aeruginosa

VancomycinIs not recommended as a standard

part of the initial antibiotic regimen for fever and Neutropenia

Clinical indications: Catheter-related infection Skin or soft-tissue infection Pneumonia Hemodynamic instability

If no improvement?Empirical antifungal coverage should

be considered in patients who have persistent fever after 4–7 days of a broad-spectrum antibacterial regimen and no identified fever source.

If an infection is documented, for how long ABs should be continue?Resolution of signs and symptoms of

infectionAlways treat 10-14 days for :

Bloodstream infection

Soft tissue infection

Pneumonia

If infection is undocumented, for how long ABs should be continue?

Patient can be changed from IV to PO treatment if a febrile after 3 days of therapy and clinically stable

Use fluoroquinolone (Levofloxacin ) for remainder of neutropenia

Prophylaxis

Indication of prophylaxisAllogeneic hematopoietic stem cell

transplant recipients.

Those undergoing intensive induction or salvage-induction chemotherapy for leukemia.

prolonged and profound neutropenia (ANC <100 cells/mm3 for >7 days).

Abs Fluoroquinolone (Levofloxacin)

Antifungal Fluconazole, itraconazole, voriconazole and caspofungin are all acceptable alternatives.

Antiviral Acyclovir Herpes seropositive recieving agressives chemotherapy.

What Is the Role of Growth Factors (neupogen) in Management?

CSFs are not generally recommended for treatment of established fever and neutropenia

CSF should be considered as Prophylactic only.

What environmental precautions should be taken when managing FN?Hand hygiene is the most effective

means of preventing transmission of infection in the hospital .

Patients should be placed in private (ie, single patient) rooms with air exchanges and particulate air filtration.

Plants and dried or fresh flowers should not be allowed.

Encourage health care workers to report their illnesses or exposures.

Thank you