Neutropenic Fever and Cancer

Chemotherapy causes neutropenia in 10-50% of patients with solid tumors and > 80% of patients with hematologic malignancies during chemotherapy cycle

Fever: ≥ 38.3 C (101 F) or ≥ 38.0 C (100.4 F) over 1-hour period

Neutropenia: Absolute neutrophil count < 500 cells/mm3

MASCC score

Multinational Association for Supportive Care in Cancer (MASCC) Score

Criteria	Points
Burden of febrile neutropenia	5 (if mild) or 3 (if moderate)
No hypotension (SBP ≥ 90 mmHg)	5
No COPD	4
Solid tumor or hematologic malignancy with no previous fungal infection	4
No dehydration requiring parenteral fluids	3
Outpatient status	3
Age <60 years	2

High Risk Patients (require admission)

• MASCC score <21 OR
• Any of clinical findings:
  • Prolonged (>7 days duration) and profound neutropenia (ANC ≤100 cells/mm3)
  • Hypotension
  • Pneumonia
  • New abdominal pain
  • Neurologic changes

Low Risk Patients (may be eligible for outpatient tx)

• MASCC score ≥21
• Brief (≤7 days duration) neutropenic periods and few co-morbidities

Workup

• CBC, BUN/creatinine, electrolytes, AST/ALT, bilirubin
• Chest xray, if respiratory signs or symptoms
• 2 blood cultures (1 central line lumen if present + 1 peripheral vein, or 2 peripheral veins)

Antibiotic Treatment

Monotherapy

• Antipseudomonal beta-lactam (eg. cefipime, carbapenem, pip-tazo)
• Vancomycin is not always indicated in cancer patients with a neutropenic fever.
• Add vancomycin only if suspect catheter-related infection, skin/soft tissue infection, pneumonia, hemodynamic instability, colonization with MRSA/VRE/PCN-resistant Strep pneumoniae
• For penicillin allergy: Ciprofloxacin + clindamycin, or aztremonam + vancomycin
• Oral medication options for outpatient: Ciprofloxacin + amoxicillin-clavulanate

Central line-associated blood stream infection (CLABSI)

Remove catheter: Consider removal if any of following:

• Caused by S. aureus, P. aeruginosa, fungi, mycobacteria
• Tunnel infection
• Pocket site infection
• Septic thrombosis
• Endocarditis
• Sepsis with hemodynamic instability
• Bacteremia despite ≥72 hours of antibiotics

Keep catheter and treat with antiobitics: If coagulase-negative staph

References

• Fairefield AG et. al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer. 2010 update by the IDSA. Clinical Infectious Disease 2011; 52 (4): e56-93. [PubMed]