Risk assessment of adults with chemotherapy-induced neutropenia
- Eric Bow, MD
Eric Bow, MD
- Professor, Departments of Medical Microbiology and Infectious Diseases, and Internal Medicine
- The University of Manitoba
Cancer patients receiving systemic antineoplastic therapy sufficient to adversely affect myelopoiesis and the developmental integrity of the gastrointestinal mucosa are at risk for invasive infection due to colonizing bacteria and/or fungi that translocate across intestinal mucosal surfaces damaged by cytotoxic therapy. Since the magnitude of the neutrophil-mediated component of the inflammatory response may be muted in neutropenic patients , a fever may be the earliest and only sign of infection.
It is critical to recognize neutropenic fever early and to initiate empiric systemic antibacterial therapy promptly in order to avoid progression to a sepsis syndrome and possibly death. It is also important to assess the risk of serious complications in patients with neutropenic fever, since this assessment will dictate the approach to therapy, including the need for inpatient admission, intravenous antibiotics, and prolonged hospitalization .
This topic will provide an overview of the risk assessment for patients with neutropenic fever. An overview of neutropenic fever syndromes and the prevention and treatment of neutropenic fever syndromes in cancer patients at high and low risk for serious complications are presented separately; the diagnostic approach to patients presenting with neutropenic fever is also discussed elsewhere. (See "Overview of neutropenic fever syndromes" 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" 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 "Diagnostic approach to the adult presenting with neutropenic fever".)
Fever — Fever in neutropenic patients is defined as a single oral temperature of ≥38.3°C (101°F) or a temperature of ≥38°C (100.4°F) sustained over a one-hour period . This is discussed in greater detail separately. (See "Overview of neutropenic fever syndromes", section on 'Definitions'.)
Neutropenia — The definition of neutropenia varies from institution to institution, but neutropenia is usually defined as an absolute neutrophil count (ANC) <1500 cells/microL and severe neutropenia as an ANC <500 cells/microL or an ANC that is expected to decrease to <500 cells/microL over the next 48 hours [2,3]. The risk of clinically important infection rises as the neutrophil count falls below 500 cells/microL and is higher in those with a prolonged duration of neutropenia (>7 days). For the purposes of this discussion, we are defining neutropenia as an ANC <500 cells/microL.
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- CATEGORIES OF RISK
- RISK FACTORS FOR NEUTROPENIC FEVER
- Patient-related predictors
- Disease-related predictors
- Anti-cancer treatment-related predictors
- RISK OF SERIOUS COMPLICATIONS
- Our definitions of low-risk and high-risk patients
- Risk based on underlying disease
- - IDSA risk assessment
- High risk
- Low risk
- - NCCN risk assessment
- High risk
- Low risk
- Intermediate risk
- MASCC score
- - Serious medical complications
- Clinical Index of Stable Febrile Neutropenia
- Risk of sepsis
- RISK OF TREATMENT FAILURE
- SUMMARY AND RECOMMENDATIONS