febrile neutropenia

• related: Hemeonc, notes

Neutropenic prophylaxis

• antiviral: acyclovir if HSV+
• antifungal
  • fluconazole if on cytarabine/venetoclax
  • posaconazole if on 7+3, cytarabine/daunorubicin/midaustaurin
• antibacterial
  • moxifloxacin inpatient
  • levofloxacin ambulatory

• maintain gram negative coverage until ANC resolves

Febrile neutropenia is generally defined as a temperature >38.3 C (>101 F) and an absolute neutrophil count <500/mm3.  Most cases are due to gram-positive pathogens such as Staphylococcus epidermidis (most common), Staphylococcus aureus, and streptococci, but gram-negative bacteria (eg, Pseudomonas) are isolated in approximately 25% of cases and are often associated with more severe illness.

Monotherapy with an anti-pseudomonal beta-lactam (eg, piperacillin-tazobactam, cefepime) or a carbapenem is considered first-line treatment in the inpatient setting.  Studies have shown no improvement in mortality with the routine addition of a second agent (eg, vancomycin) targeting gram-positive pathogens.  Indications for vancomycin include:

• Hemodynamic instability
• Severe sepsis
• Pneumonia
• Positive blood cultures for a gram-positive organism (prior to speciation results)
• Suspected catheter-related infection (eg, chills during infusion, cellulitis around entry site)
• Skin or soft-tissue infection