Diagnostic approach to the adult presenting with neutropenic fever
- John R Wingard, MD
John R Wingard, MD
- Professor of Medicine
- University of Florida College of Medicine
Fever occurs frequently in patients with chemotherapy-induced neutropenia. Factors that contribute to the pathogenesis of neutropenic fever include the direct effects of chemotherapy on mucosal barriers and immune deficits related to the underlying malignancy or other immunosuppressive conditions or therapies. Prior to the era of empiric antibiotic therapy, infections accounted for most episodes of neutropenic fever and approximately 70 percent of the mortality in neutropenic acute leukemia patients . Because of the routine use of prompt empiric antibiotics, infections are documented less frequently today.
Although the majority of patients with neutropenic fever do not have a documented infection, consensus guidelines recommend that all patients with neutropenic fever be promptly evaluated and treated with empiric broad-spectrum antibiotics . This approach is indicated since it is difficult to distinguish life-threatening infections from less serious infections in this patient population, and infection may progress rapidly in such patients. Furthermore, better outcomes are seen with prompt therapy .
The diagnostic evaluation of patients presenting with neutropenic fever will be reviewed here. An overview of neutropenic fever syndromes as well as the risk assessment and management of patients with neutropenic fever are presented separately. (See "Overview of neutropenic fever syndromes" and "Risk assessment of adults with chemotherapy-induced neutropenia" and "Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients)" and "Treatment and prevention of neutropenic fever syndromes in adult cancer patients at low risk for complications" and "Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults" and "Prophylaxis of invasive fungal infections in adults with hematologic malignancies" and "Prophylaxis of invasive fungal infections in adult hematopoietic cell transplant recipients".)
Guidelines have been developed for the evaluation and management of fever in neutropenic patients with cancer [2,4,5]. The recommendations below are generally in keeping with the 2010 Infectious Diseases Society of America (IDSA) guidelines . (See 'Society guideline links' below.)
Fever — Fever in neutropenic patients is defined as a single oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) sustained over a one-hour period . The definition of fever is discussed in greater detail separately. (See "Overview of neutropenic fever syndromes", section on 'Fever'.)
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- Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56.
- Zuckermann J, Moreira LB, Stoll P, et al. Compliance with a critical pathway for the management of febrile neutropenia and impact on clinical outcomes. Ann Hematol 2008; 87:139.
- National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Prevention and treatment of cancer-related infections. Version 2.2014. http://www.nccn.org (Accessed on November 06, 2014).
- Flowers CR, Seidenfeld J, Bow EJ, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013; 31:794.
- US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Common terminology criteria for adverse events (CTCAE). http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf (Accessed on February 16, 2012).
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- Hirsch HH, Martino R, Ward KN, et al. Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013; 56:258.
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- PATIENT EVALUATION
- Risk assessment
- Physical examination
- - Lungs
- - Abdomen
- - Intravenous catheter sites
- - Skin and mucous membranes
- - Perianal region
- Routine laboratory tests
- Serum fungal markers
- Microbiology and other diagnostic testing
- INITIATION OF EMPIRIC THERAPY
- EVALUATION OF PERSISTENT OR RECURRENT FEVER
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS