Neutropenic Fever

Neutropenic fever

Pyrexia >38° C for over one hour duration or >38.3°C on one occasion in a neutropenic adult:.

If likely to have protracted (> 5 days) neutropenia, patient should be nursed in a room with HEPA filtered air (Ward 2D in CUH).

Defined as neutrophils ≤1.
Functional neutrophilia - following recent chemotherapy even with levels >1.
Myelodysplastic patients have functional neutropenia even with "normal" neutrophil levels.
In general, patients attending haematology OPD monthly, have are at risk on neutropenia.

Bacteraemia in 30% (60% of which is Gram Positive - Staphylococcus from lines or Strep in mucositis)
Most dangerous are Gram negative from patients bowel
Fungal infections are uncommon and associated with prolonged neutropenia and broad spectrum antibiotics
Netilmicin no longer available
3rd generation cephalosporin use is associated with C difficile and Vancomycin resistant enterococci

Full clinical examination but note particularly: Pulse, BP, mouth, chest, perineum, line sites, skin, fundi.

FBC, U&E Cr., LFT, CRP, CXR, sinus or dental x rays if symptomatic
Blood culture - peripheral and central line if present
Swabs from appropriate inflamed sites
MSU if symptomatic
Faeces if diarrhoea and/or if fungal infection suspected, check C. difficile toxin
Aspergillus precipitans and PCR
Serology, mouthwash, vesicle fluid for virology if indicated

Infection	Neutropenic sepsis
Most likely organisms	Aerobic gram negative rods, Gram positives usually associated with central venous catheters.
Empiric treatment	Piperacillin-tazobactam 4.5g q6h iv plus Gentamicin 5mg/kg q24h iv (max 480mg q24h). For line infection, septic shock, or MRSA colonisation: add Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv. Only if documented Hx of ESBL: Meropenem 1g tds iv.
In penicillin allergy	Ciprofloxacin 400mg q8h iv plus Gentamicin 5mg/kg q24h (max 480mg q24h) iv plus Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv. ADD Metronidazole 500mg q8h iv if mucositis or GI symptoms present. If docemented Hx of ESBL/MDRO: Check sensitivities. If sensitive and no recent exposure: as above. Otehrwise seek advice from micro.
Duration
Comments	Avoid Gentamicin in multiple myeloma / renal impairment / platinum based chemotherapy, and use ciprofloxacin instead. Vancomycin dosing Please see local Neutropenic Sepsis guideline for more details. Seek daily review of Gentamicin. Gentamicin should not be required for more than 7 days Seek advice on oral options and duration of treatment.

Content by Dr Íomhar O' Sullivan 06/09/2004. Last reviewed Ms. Mala Shah,Dr. ÍOS 6/05/15.