[22] Febrile Neutropenia

Question 1

When is febrile netropenia most often seen?

Answer 1

As a result of cytotoxic therapy

Question 2

When does the neutrophil count usually reach its lowest level?

Answer 2

5-10 days after the last dose of chemotherapy

Question 3

Other than after cytotoxic therapy, when can neutropenia occur in cancer?

Answer 3

• After radiotherapy

- Part of pancytopenia

Question 4

When can neutropenia follow radiotherapy?

Answer 4

When large volumes of bone marrow are irradiated

Question 5

Why might cancer cause pancytopenia?

Answer 5

Due to malignant infiltration of the marrow

Question 6

What is febrile neutropenia defined as?

Answer 6

• Oral temperature of 38.5 or above, and 2 consecutive readings of 38 or above for 2 hours
• Absolute neutrophil count of 0.5x10^9/L or less

Question 7

When should there be a high index of suspicion for febrile neutropenia?

Answer 7

In all patients who have recently received chemotherapy

Question 8

What is the significance of fever in a cancer patient?

Answer 8

Although there are other causes of fever in a cancer patient, infection should always be assumed unless proven otherwise

Question 9

Are the signs and symptoms of febrile neutropenia significant?

Answer 9

No, they can be minimal

Question 10

When in particular might the signs and symptoms of febrile neutropenia be minimal?

Answer 10

In patients on corticosteroids

Question 11

What should the history include in febrile neutropenia?

Answer 11

• Whether the patient belongs to a high risk group
• Duration since last chemotherapy cycle (if applicable)
• Any recent blood produces
• Any intravascular devices, e.g. cannula, central lines

Question 12

What are the high risk groups for febrile neutropenia?

Answer 12

• Active neoplastic disease
• Recent course of chemotherapy
• Immunosuppressant therapy
• Immunosuppressive illness, e.g. HIV
• CKD

Question 13

What laboratory investigations should be done in febrile neutropenia?

Answer 13

Infection screen comprising of;

• Blood cultures
• MSU
• Chest x-ray
• Swabs for cultures

Question 14

What blood cultures should be done in febrile neutropenia?

Answer 14

• Peripheral

- Central line if present

Question 15

What swabs should be done in febrile neutropenia?

Answer 15

• Throat

- Central line site

Question 16

Are additional microbiological assessments required in febrile neutropenia?

Answer 16

Not unless there are localising signs of infection

Question 17

What is the basic management of febrile neutropenia?

Answer 17

Sepsis 6 bundle

Question 18

What should choice of empirical antibiotics be based on in febrile neutropenia?

Answer 18

Local hospital policies, agreed with microbiologists and based on local antibiotic resistance patterns

Question 19

What is first line empirical antibiotic therapy in febrile neutropenia?

Answer 19

Either monotherapy with tazocin or meropenum, or with the addition of gentamicin

Question 20

What can be added to empirical antibiotic therapy for febrile neutropenia when anaerobic infection is present?

Answer 20

Metronidazole

Question 21

What can be added to empirical antibiotic therapy for febrile neutropenia when gram-positive infection is suspected?

Answer 21

One of;

• Flucloxacillin
• Vancoymycin
• Teicoplanin

Question 22

What should empirical antibiotics be adjusted on the basis of?

Answer 22

Culture results

Question 23

What is the problem with determining suitable antibiotics from culture results in febrile neutropenia?

Answer 23

Cultures are often negative

Question 24

What should be done if there is no response to antibiotics after 36-48 hours in febrile neutropenia?

Answer 24

• Antibiotics should be reviewed with microbiological advice
• Anti-fungal cover should be considered

Question 25

What does recombinant human granulocyte-colony stimulating factor (G-CSF) do?

Answer 25

Stimulates the production of neutrophils in the bone marrow

Question 26

How is G-CSF administered?

Answer 26

SC

Question 27

What is the purpose of G-CSF?

Answer 27

It may reduce the duration of chemotherapy-induced neutropenia, and thereby reduce the incidence of associated sepsis

Question 28

Does G-CSF improve survival?

Answer 28

Currently no evidence that it improves survival

Question 29

Can G-CSF be used prophylactically?

Answer 29

In some cases, but not routinely

Question 30

Give an example of when G-CSF might be used prophylactically in some cases?

Answer 30

Following chemotherapy

Question 31

When can G-CSF be used in an established infection?

Answer 31

Can be given alongside antibiotics to counteract infection

Question 32

What is the mortality from febrile neutropenia in people with solid tumours?

Answer 32

5%

Question 33

What is the mortality from febrile neutropenia in people with haematological malignancies?

Answer 33

11%

Question 34

What does successful management of febrile neutropenia depend on?

Answer 34

Early recognition

Question 35

How can early recognition of febrile neutropenia be achieved?

Answer 35

• Patients should be educated to monitor their symptoms, including body temperature
• Should be given clear, written instructions on when and how to contact appropriate services in the event of concerns