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Neutropenic Patients with Unexplained Fever

Neutropenia: Neutrophil count, <500/mm3 or <1,000/mm3 with predicted decline to

Evaluation: Cultures of blood (peripheral and catheter), lesions, and diarrheal stools; chest radiograph; complete blood count; determinations of levels of transaminases, Na, K, creatinine, and blood urea nitrogen. Other tests as indicated.

Guidelines for Treatment

Initial antibiotic therapy: One of three regimens.

If vancomycin is needed (criteria given):

1. Vancomycin + ceftazidime

$ If vancomycin is not needed:

2. Monotherapy: ceftazidime or imipenem (cefepime or

meropenem)

or

3. Duotherapy: aminoglycoside + antipseudomonal beta-lactam.

3. Duotherapy: aminoglycoside + antipseudomonal beta-lactam.

Afebrile within first 3 days of treatment:

$ If no etiology identified:

Low risk (defined): change to oral antibiotic (cefixime or quinolone).

High risk (defined): continue same antibiotics.

$ If etiology identified: adjust to most appropriate treatment.

Persistent fever during first 3 days of treatment:

$ Reassess on day 4 or 5.

If no change: continue antibiotics; consider stopping vancomycin if cultures are negative.

If progressive disease: change antibiotics.

If febrile on days 5-7: add amphotericin B with or

In general, a temperature clearly above the normal temperature for the patient constitutes a febrile state. A single oral temperature of $38.3EC (101EF) in the absence of obvious environmental causes is usually considered fever. A temperature of $38.0EC (100.4EF) over at least 1 hour indicates a febrile state. This definition has also been recommended for use in studies to evaluate drugs for the treatment of febrile neutropenic patients [8]. It is important to avoid the use of a rectal thermometer in neutropenic patients. Although uncommon, a neutropenic patient who is afebrile but who has signs and symptoms compatible with infection

When the neutrophil count decreases to < 1,000 cells/mm3, increased susceptibility to infection can be expected, with the frequency and severity generally inversely proportional to the neutrophil count [5, 6]. Patients with neutrophil counts of #500/mm3 are at considerably greater risk for infection than those with counts of 1,000/mm3, and patients with counts of <~100/mm3 are at greater risk than those with counts of 500/mm3. In addition to the number of circulating neutrophils. the rate of decline

Evaluation

Empirical administration of broad-spectrum antibiotics is necessary for febrile neutropenic patients because the currently available diagnostic tests are not sufficiently rapid, sensitive. or specific for identifying or excluding the microbial cause of a febrile episode. If untreated, these infections may be rapidly fatal in the neutropenic host. Although molecular diagnostic technology provides considerable promise, it has added little useful support to the immediate evaluation of febrile neutropenic patients to