Neutropenic Fever

1. Diagnosis
   1. Fever: Temperature at least 101 F (38.3 C) and
   2. Neutropenia: Absolute Neutrophil Count <500/mm3
2. Labs
   1. Complete Blood Count with differential
      1. Determine Absolute Neutrophil Count (ANC)
   2. Blood Cultures
   3. Site-specific cultures as indicated
   4. Liver transaminases
   5. Renal Function tests
      1. Blood Urea Nitrogen
      2. Serum Creatinine
3. Evaluation
   1. See Neutropenic Fever Clinical Decision Rule
   2. Use Clinical Decision Rule to define high or low risk
   3. High risk criteria
      1. Inpatient
      2. Serum Creatinine >2 mg/dl
      3. Liver Function Tests >3 fold increased above normal
      4. Pneumonia
      5. Uncontrolled or progressive cancer
      6. Serious comorbidity
      7. Absolute Neutrophil Count <100/mm
      8. Absolute Neutrophil Count <500/mm
   4. Low risk criteria
      1. Outpatient
      2. No comorbidity
      3. Neutropenia of short duration
      4. Serum Creatinine <2 mg/dl
      5. Liver Function Tests <3 fold increased above normal
      6. Active and independent functional status
   5. References
      1. Hughes (2002) Clin Infect Dis 34:730-51
4. Management: General
   1. Evaluation (see above) determines level of risk
   2. Indication for Vancomycin protocol as listed below
   3. Consider Antifungals if no improvement in 3 days
   4. Other medications not routinely used
      1. Antiviral medications
      2. Granulocyte transfusions
      3. Colony stimulating factors
5. Management: Low risk
   1. Duration of antibiotics: Based on re-evaluation day 3-5
   2. Option 1: Oral antibiotics
      1. Ciprofloxacin PO and
      2. Augmentin PO
   3. Option 2: Intravenous antibiotics
      1. See High Risk cases below
6. Management: High risk with Vancomycin Needed
   1. Indications for Vancomycin
      1. Inpatient setting where MRSA is common
      2. Serious catheter related infection
      3. Patient known to be colonized
         1. Methicillin Resistant Staphlyococcus aureus (MRSA)
         2. Penicillin Resistant Pneumococcus (PRP)
         3. Cephalosporin-resistant pneumococci
      4. Initial Blood Cultures positive for Gram Positives
      5. Cardiovascular compromise
   2. Protocol
      1. Vancomycin and
      2. Cephalosporin
         1. Cefepime or
         2. Ceftazidime or
         3. Carbapenem
      3. Consider adding Aminoglycoside
7. Management: High risk without Vancomycin Needed
   1. Option 1: Intravenous monotherapy antibiotics
      1. Cefepime or
      2. Ceftazidime or
      3. Carbapenem
   2. Option 2: Intravenous 2 drug therapy
      1. Aminoglycoside and
      2. Penicillin or Cephalosporin
         1. Extended Spectrum Penicillin for Pseudomonas or
         2. Cefepime or
         3. Ceftazidime
         4. Carbapenem
8. References
   1. Higdon (2006) Am Fam Physician 74:1873-80
   2. Hughes (2002) Clin Infect Dis 34:730-51
   3. Viscoli (1998) J Antimicrob Chemother 41:S65-80