#Neutropenia and Fever
-Definition: Temperature > 38.3°C (101°F) + ANC < 500. [NB: Fever in a neutropenic patient is defined as a single temperature >38.3°C (101°F) or a sustained temperature >38.0°C (100.4°F) for >1 hour.]
-Admit to Med-Surg
-CBC, Manual diff, Blood cultures, CMP, Lactate, Procalcitonin, UA, UCx, Sputum Cx, CXR,
-1 Liter bolus
-Cefepime 2g q 12h (antipseudomonal drug)
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The drug of choice for neutropenic fever is a monotherapy that covers pseudomonas. In patients with normal renal function, the doses of these drugs are:
Cefepime – 2 g IV q8h
Meropenem – 1 g IV q8h
Imipenem-cilastatin – 500 mg IV q6h
Piperacillin-tazobactam – 4.5 g IV q6-8h
Ceftazidime – 2 g IV q8h (use this only if you must)
NB: The IDSA article below has a good algorithm to use when approaching neutropenic patients.
Differential Diagnosis of Neutropenia.
How to calculate the Absolute Neutrophil Count (ANC).
**Most patients on chemotherapy will experience a nadir in her absolute neutrophil count (ANC) five to ten days after completion of a chemotherapy session.
Vignette:
Pt in the 50s, PMH of HIV and aggressive cancer (chemotherapy started two weeks prior to encounter), was being treated for pancytopenia presents with 101.3 temperature at home associated with chills and sweats. The patient had also been coughing, having a runny nose, congestion, sore throat, as well as dysuria and frequency. Pt is a currents smoker with a 35 pack yr history. ROS is otherwise negative. Oncologist sent the patient to the ED for evaluation.
Resources:
1.IDSA Guidlines for Neutropenic Fever – https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/FN.pdf
2.https://www.uptodate.com/contents/treatment-of-neutropenic-fever-syndromes-in-adults-with-hematologic-malignancies-and-hematopoietic-cell-transplant-recipients-high-risk-patients