Hematology Question 39 Instructor

What is the definition of febrile neutropenia, and how should it be managed?

Points of discussion:

  • Febrile neutropenia (FN) is defined as an oral temperature >38.5°C or two consecutive readings of >38.0°C for 2 h and an absolute neutrophil count <0.5 × 109/l, or expected to fall below 0.5 × 109/l
  • Every patient requires:
    • Blood cultures (peripheral and Port/PICC sites)
    • Urine culture
    • CXR
    • +/- culture of other sources of possible infection (eg.. C. difficile collection if diarrhea, throat swab if odynophagia)
  • Special considerations:
    • Sinusitis
    • Herpes simplex
    • Herpes zoster
    • Thrush
  • Avoid acetaminophen orders which may mask fevers (can order prn acetaminophen if fever already document, please avoid standing acetaminophen orders)
  • Avoid suppositories, enemas, or rectal probing while neutropenic

Treatment:

  • Neupogen (5ug/kg) until neutrophils at least >0.5 x 10 9/L
  • No evidence to support single vs double agent therapy:
    • single agent β-lactam such as cefepime, carbapenem or piperacillin / tazobactam
  • There is no role for addition of aminoglycosides unless critically ill with suspected gram negative infection
  • VANCO or Linezolid
    • Port / line infection
    • Mucositis
    • MRSA colonization
    • Recent quinolone prophylaxis
    • Prolonged fever

Friefeld A et al. Clinical Practice Guideline for the use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 update by the Infectious Diseases Society of America. CID 2011:


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