Updated: 10/30/2020

Neutropenic Fever

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Snapshot
  • A 68-year-old woman presents to the emergency department due to fatigue, malaise, and a subjective fever. Her symptoms began approximately 1 week ago. Medical history is significant for small cell lung cancer recently treated with doxorubicin plus cyclophosphamide and etoposide. Her temperature is 102°F (38.9°C) and blood pressure is 100/80 mmHg. A complete blood count with differential is remarkable for an absolute neutrophil count of 320 cells/mm3. She is admitted to the hospital and administered intravenous cefepime.
Introduction
  • Definition
    • a single fever of ≥ 101°F (38.3°C) in a patient with an absolute neutrophil count (ANC) < 500 cells/mm3
    • a sustained fever of ≥ 100.4°F (38°C) in a patient with an ANC of < 500 cells/mm3
  • Epidemiology
    • incidence
      • commonly seen in patients receiving cytotoxic chemotherapy
  • Pathophysiology
    • chemotherapy impairs host immunity, predisposing the patient to infection
  • Prognosis
    • delayed or inadequate empiric antibiotics leads to worse outcomes
Presentation
  • Symptoms/physical exam
    • fever
    • tachycardia
    • tachypnea
Studies
  • Initial testing includes
    • complete blood count (CBC) with differential
    • complete metabolic panel
    • blood cultures
    • urine culture
    • culture of sites concerning for infection
  • Other studies
    • chest radiography
      • in patients with respiratory findings
      • a CT scan of the chest is typically ordered if chest radiography is unrevealing
Treatment
  • Medical
    • high-risk patients (requires hospitalization)
      • intravenous empiric antibiotics that cover for Pseudomonas aeruginosa 
        • medications
          • cefepime
          • piperacillin-tazobactam
          • imipenem-cilastatin
    • low-risk patients (can be treated as an outpatient) or patients with neutropenia without a fever
      • oral empiric antibiotics
        • medications
          • oral
            • ciprofloxacin 
            • levofloxacin
            • amoxicillin-clavulanate
Complications
  • Sepsis syndrome
  • Death

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Questions (2)
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(M2.ID.13.120) A 13-year-old male is admitted to the hospital for treatment of acute lymphoblastic leukemia. During his hospital course, he develops a fever of 39.0 degrees Celsius. A CBC demonstrates a leukocyte count of <500 /mm^3. Which of the following is the most appropriate initial management of this patient?

QID: 106215
1

Granulocyte colony-stimulating factor (G-CSF)

32%

(27/85)

2

IV ceftazidime

45%

(38/85)

3

Oral doxycycline

0%

(0/85)

4

Oral ciprofloxacin and amoxicillin/clavulanic acid

8%

(7/85)

5

Strict quarantine and hand-washing

14%

(12/85)

M 7 E

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