80% of patients receiving chemotherapy have at least one episode of febrile neutropenia
Genetic predisposition like mannose-binding lectin deficiency doubles the duration of fever
Investigations
Blood cultures from all lines, including central lines, repeated at least every 72h if it continues
Urinalysis +/- urine culture
CXR regardless of symptoms
Nasopharyngeal swab for respiratory viruses
Stool for C.diff, if appropriate
If ongoing fevers, consider CT chest
Management
In general, broad-spectrum antimicrobials until fever resolved x48h AND neutrophils > 0.5 AND minimum course of 5-7 days, then consider stepping down to treat underlying infection only
Empiric antibiotic choice depends on site but should include Pseudomonal coverage
Piptazo 4.5g q8h
Ceftazidime 2g q8h
Ciprofloxacin 400 q12h and gentamicin 5-7mg/kg q24h
Meropenem 1g q8h
Consider adding other agents empirically if concern for:
MRSA or SSTI or severe mucositis or septic shock: vancomycin 15mg/kg q12h, reassessed at 48h
Typhlitis: ensure adequate anaerobic coverage, may need to add metronidazole 500mg q12h
VRE: linezolid or daptomycin
ESBL: carbapenem
KPC: polymixin-colistin or tigecycline
If still febrile and neutropenic for 4 to 7 days despite antibiotics, add antifungal (especially if not on prophylaxis)
Caspofungin 70mg then 50mg daily
Liposomal amphotericin B 3mg/kg daily
Anidulafungin if renal or hepatic dysfunction
In high-risk patients, can consider adding GCSF (Neupogen/Filgrastim)
In some low-risk patients, can step down to amox/clav AND cipro 750
Expected duration of severe neutropenia ≤7 days, AND
No comorbidities or significant hepatic or renal dysfunction
Mostly, these patients are receiving chemotherapy for solid tumours
Monitor for myeloid reconstitution syndrome (similar to IRIS) while neutrophils are recovering
