Febrile Neutropenia

Question 1

Define neutropenic fever.

Question 2

Calculate absolute neutrophil count (ANC).

Answer 2

Count both neutrophils and bands!!

Question 3

Identify high-risk neutropenia.

Answer 3

• Older age
• Chemotherapy regimen - risk increases as number of cycles increases, more myelosuppressive agents
• Hematologic malignancy
• Concomitant radiation

Question 4

Identify low-risk neutropenia.

Answer 4

• Burden of febrile neutropenia with no or mild symptoms
• No hypotension (systolic > 90 mmHg)
• No COPD
• Solid tumor or hematological malignancy with no previous fungal infection
• No dehydration requiring parenteral fluids
• Burden of febrile neutropenia with moderate symptoms
• Outpatient
• Age < 60 years

Question 5

Design a treatment plan for a patient with febrile neutropenia, including antibiotic dosing!!

Answer 5

• Low-risk: Ciprofloxacin and augmentin PO; do not use if received quinolone prophylaxis for FN; continue until ANC>500
• High-risk: monotherapy anti-pseudo beta lactam (pip/tazo, cefepime, meropenem, imipenem/cilistatin); aminoglycoside or ciprofloxacin may be needed for extended gram negative coverage

Question 6

Modify a patient’s febrile neutropenia treatment plan based on changes in temperature, ANC, and other patient factors.

Answer 6

• Safe to D/C antibiotics if patient has been afebrile for 72 hours regardless of ANC
• Can stop vancomycin after 48 hours
• FN prophylaxis: ANC < 100 for 7 days or more - prophylaxis with levofloxacin 500 or 750 mg PO daily or ciprofloxacin 500 mg PO Q12H
• Antiviral prophylaxis: HSCT, hematologic malignancy, and purine analog patients; acyclovir 400 mg PO BID or 800 mg PO BID or valacyclovir 500 mg PO daily; continue for 30 days after HSCT
• Antifungal prophylaxis: neutropenia expected to last > 7 days (AML, HSCT); fluconazole 200-400 mg daily
• PCP/PJP prophylaxis: acute lymphatic leukemia, receiving fludarabine or alemtuzumab, glioblastoma multiforme pts. receiving chemorad. w/ temozolomide x 6 weeks, or receiving prednisone eqiv. dose of 20 mg/day x 1 month; TMP-SMX 1 tab daily MWF or 1 tab BID Sat/Sun, inhaled pentamidine 300 mg via nebulizer q month, dapsone or pyrimethamine alt. for not tolerating other two agents

Question 7

Identify febrile neutropenia patients who should receive vancomycin.

Answer 7

• Pneumonia
• Catheter/line infection (known or suspected)
• Blood cultures growing gram positive bacteria
• Colonization or history of infection with MRSA or drug resistant pneumococci
• Sepsis, hemodynamic instability (hypotension, increased heart rate)
• Skin or soft tissue infection