Oncologic Emergencies: Febrile Neutropenia

Question 1

FN definition

Answer 1

single temperature >38.3ºC OR temperature >38ºC for over 1 hour PLUS ANC <500 cells/mcL OR ANC <1000 but expected to drop to <500 in 48 hours

Question 2

FN risk factors

Answer 2

Age ≥65
previous chemo or radiation
pre-existing neutropenia or bone marrow infiltration with tumor
poor performance status (ECOG 3-4)
female
comorbidities (poor renal, hepatic, or cardiac function; HIV or active infection; surgery)
low BMI or BSA
specific genetic polymorphisms

Question 3

FN infection risk: low

(How long is the neutropenia expected to last?)

Answer 3

Standard chemo for most solid tumors
Anticipated neutropenia <7 days

Question 4

FN infection risk: intermediate

Answer 4

Autologous HCT
Lymphoma
Multiple myeloma
CLL
Purine analog therapy
Anticipated neutropenia 7-10 days

Question 5

FN infection risk: high

Answer 5

Allogeneic HCT
Acute leukemia
Alemtuzumab therapy
GVHD therapy treated with high-dose steroids
Anticipated neutropenia >10 days

Question 6

FN workup

Answer 6

History and PE
Lab tests: CBC with diff, renal function, electrolytes, LFTs
Microbial evaluation: get blood cultures
Chest x-ray if necessary
Patient risk assessment and classification

Question 7

FN prophy: low risk

Answer 7

No prophy (unless prior HSV exposure, then they get viral prophy)

Question 8

FN prophy: intermediate risk

Answer 8

Consider bacterial and fungal prophy
Get viral prophy

Question 9

FN prophy: high risk

Answer 9

Consider fungal prophy
Get bacterial and viral prophy

Question 10

MASCC score: low risk

Answer 10

> 21

Can get outpatient treatment with PO ABX if tolerated

Question 11

Low risk ABX treatments

Answer 11

Ciprofloxacin 750mg BID and Augmentin 875/125 mg BID

PO options not appropriate for patients on fluoroquinolone prophy at the time of diagnosis, patients with N/V

Question 12

MASCC score: high risk

Answer 12

<21

Inpatient management with broad-spectrum ABX

Question 13

ABX inpatient in FN should cover for what?

Answer 13

Pseudomonas

Question 14

Inpatient ABX treatments for FN

Answer 14

Cefepime 2g q8h
Pip/tazo 4.5g q6h OR via extended infusion
Meropenem 1g q8h

Question 15

When to add double gram-negative coverage

Answer 15

Concern for resistant organisms

Question 16

When to add MRSA coverage

Answer 16

catheter-related infections, SSTIs, pneumonia, hemodynamic insufficiency/sepsis, mucositis

Question 17

ABX that cover MRSA

Answer 17

Vanco, dapto, linezolid

Can stop if cultures come back negative for gram + infection

Question 18

When to add fungal coverage

Answer 18

patients who don’t respond to initial therapy in 4-7 days, have positive fungal markers or cultures

Question 19

Antifungal options

Answer 19

Fluconazole, posaconazole, voriconazole, isavuconazole, micafungin, caspofungin

Question 20

Duration of FN treatment: unidentified infection

Answer 20

Continue until ANC >500 and afebrile for ≥2 days

Question 21

Duration of FN treatment: SSTi

Answer 21

7-14 days

Question 22

Duration of FN treatment: gram-negative bloodstream infection

Answer 22

10-14 days

Question 23

Duration of FN treatment: gram-positive bloodstream infection

Answer 23

7-14 days

Question 24

Duration of FN treatment: bacterial sinusitis

Answer 24

7-14 days

Question 25

Duration of FN treatment: bacterial pneumonia

Answer 25

7-14 days

Question 26

Duration of FN treatment: candida

Answer 26

2 weeks