Febrile neutropenia

Cisplatin-gemcitabine renal, neuropathy, weakness, hypersensitivity, anemia Febrile neutropenia, infection, thrombocytopenia, nausea, vomiting, High (day 1) Mild (days 8 and 1 5)... 

O A risk assessment should be performed at presentation of febrile neutropenia to identify low-risk patients for potential outpatient treatment. Patients who do not meet low-risk criteria should be hospitalized for immediate parenteral administration of broad-spectrum antibacterials before culture results are obtained. 

The success of the treatment of febrile neutropenia hinges on the adequate recovery of the absolute neutrophil count and either optimal antimicrobial coverage of identified organisms or empirical coverage of unidentified organisms. 

Febrile neutropenia is a common adverse effect of the administration of cytotoxic chemotherapy. The mortality rate owing to infectious complications currently remains between 5% and 10% therefore, febrile neutropenia is considered a true oncologic emergency. Patients frequently require hospitalization for prompt administration of broad-spectrum antibiotics that are critical to avoid morbidity and mortality. 

What risk factors for febrile neutropenia does this patient have ... 

TABLE 96-1. Commonly Isolated Pathogens in Patients with Febrile Neutropenia... 

Neutropenia is defined as an absolute neutrophil count (ANC) of less than 0.5 x 10 3/ J.L (0.5 x 109/L) cells or an ANC of less than 1.0 x 103/ J.L (1.0 x 109/L) cells with a predicted decrease to less than 0.5 x 103/ J.L (0.5 x 109/L) cells. The ANC is calculated by multiplying the total white blood cell (WBC) count by the percentage of neutrophils (segmented neutrophils plus bands). Fever is defined as a single oral temperature of 38.3°C (101°F) or greater or a temperature of 38.0°C (100.4°F) or greater for at least 1 hour. The combination of these two factors defines febrile neutropenia.5 The risk of infection during the period of neutropenia depends primarily on two factors ... 

A multitude of other risk factors for febrile neutropenia have been identified (Table 96-2). Many of these are also risk factors for poor outcome in patients who experience febrile neutropenia. 

It is clear that patients with febrile neutropenia represent a heterogeneous group. Some patients are at lower risk and potentially could be treated as outpatients, thereby avoiding the risk and cost of hospitalization. The Multinational Association for Supportive Care in Cancer (MASCC) has validated a risk-assessment tool that assigns a risk score to patients presenting with febrile neutropenia7 (Table 96-3). Patients with a risk-index score of 21 or greater are identified as low risk and are candidates for outpatient therapy (discussed under Treatment ). 

Only 50% of patients with febrile neutropenia have a clinically documented infection. 

What preventative measures should be taken to decrease her risk of febrile neutropenia ... 

Macrophage 250- or 500-mcg vial size Bone pain Injection-site skin reaction older patients with AML Limited experience and lack of FDA approval for prevention of febrile neutropenia... 

TABLE 96-5. Dosing Guidelines for Empirical Antimicrobial Agents in Febrile Neutropenia... 

The CSFs should not be used routinely for treatment of febrile neutropenia in conjunction with antimicrobial therapy.5 However, the use of CSFs in certain high-risk patients with hypotension, documented fungal infection, pneumonia, or sepsis is reasonable. A recent meta-analysis demonstrated that hospitalization and neutrophil recovery are shortened and that infection-related mortality is marginally improved.14 As with prophylactic use of these agents, cost considerations limit their use to high-risk patients. 

If febrile neutropenia occurs, patient history is important ... 

Did the patient have previous episodes of febrile neutropenia What were the previous culture results to determine colonization status ... 

For patients receiving oral antibiotics either prophylacti-cally or as treatment of febrile neutropenia, counsel them that initial or persistent fever should be reported promptly and that compliance with the regimen is critical. Patients also should have easy access to medical care and adequate caregiver support. Provide information on drug interactions and adverse effects. 

Lyman GH, Kuderer NM. The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia. Crit Rev Oncol Hematol 2004 50 129-146. 

Neulasta, Pegfilgrastim, G-CSF-PEG Amgen, Inc. Infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelo-suppressive anti-cancer drugs Jan. 2002... 

Empiric therapy for febrile neutropenic patients - As monotherapy for empiric treatment of febrile neutropenic patients. In patients at high risk for severe infection (including patients with a history of recent bone marrow transplantation, with hypotension at presentation, with an underlying hematologic malignancy, or with severe or prolonged neutropenia), antimicrobial monotherapy may not be appropriate. Insufficient data exist to support the efficacy of cefepime monotherapy in such patients. 

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