Febrile neutropenia (FN) is defined as an oral temperature >38.5ºC or two consecutive readings of >38ºC for 2 hours and an absolute neutrophil count <0.5 x 109/l, or a count expected to fall below 0.5 x 109/l.
Initial assessment and investigations
1. Note presence of indwelling intravenous (IV) catheters.
2. Symptoms or signs suggesting an infection focus.
3. Knowledge of previous positive microbiology results.
4. Routine investigations: blood testing, cultures (blood, urine, sputum, and stool), skin lesion (aspirate/biopsy/swab), chest radiograph.
5. Further investigations (profound/prolonged neutropenia): high-resolution chest computed tomography, broncho-alveolar lavage.
Initial management
Low-risk patients
Patients hemodynamically stable, with no or mild symptoms, age <60 years, solid tumor/lymphoma with no previous fungal infection, no chronic obstructive pulmonary disease, and no dehydration. Inpatient oral antibacterial therapy can be safely substituted for conventional IV treatment in some low-risk FN patients. Single-agent quinolones were not inferior to combinations (quinolone with amoxicillin plus clavulanic acid) but the latter are preferred given the rise in gram-positive FN episodes.
High-risk patients
Patients with severe symptoms, hypotension, chronic obstructive pulmonary disease, dehydration, age >60 years, chronic obstructive pulmonary disease, not solid tumor, previous fungal infection, or have high-risk features as judged by the admitting doctor, should be admitted and commenced on broadspectrum IV antibiotics.
Local epidemiological bacterial isolate and resistance patterns are important in determining first-choice empirical therapy. In the subsets at high risk of prolonged neutropenia and those with bacteremia, the bactericidal activity and synergistic effect of a b-lactam antibiotic in combination with an aminoglycoside can be preferable.
See reference for more information. Naurois J, Novitzky-Basso I, Gill M. Management of febrile neutropenia: ESMO Clinical Practice Guidelines Annals of Oncology 2010;21(Supplement 5):252–256. Internet. Accessed on July 2016.