I worked on this presentation in 2017, for the Infectious disease department. My sources are: UpToDate, IDSA guidelines. Please share & give me credit to my work.

1. Management of neutropenic
fever in patients on
chemotherapy
By Dr. Tasneem Bashir
Internal Medicine resident, Al Ain
Hospital

2. Febrile neutropenia
O Fever in a neutropenic patient is defined as
a single oral temperature of ≥38.3˚C or a
temperature of ≥38.0˚C sustained over a
one-hour period.
O Neutropenia is usually defined as an
absolute neutrophil count (ANC) <1500
cells/microL
O Severe neutropenia is usually defined as an
ANC <500 cells/microL or an ANC that is
expected to decrease to <500 cells/microL
over the next 48 hours

3. Assessment of risk for complications of severe infection
High-risk patients (should be initially admitted for empirical therapy):
 prolonged (>7 days duration) and profound
neutropenia (absolute neutrophil count [ANC] <100
cells/ mm3 following cytotoxic chemotherapy)
O and/or significant medical co-morbid conditions,
including hypotension, pneumonia, new-onset
abdominal pain, or neurologic changes.
Low-risk patients (candidates for oral empirical therapy) includes:
O anticipated brief (<7 days duration) neutropenic
periods or
O no or few comorbidities.

4. O Formal risk classification may be performed using the
Multinational Association for Supportive Care in Cancer
(MASCC) scoring system.

5. O High-risk patients have a MASCC score 21 . All patients at high
risk by MASCC or by clinical criteria should be initially admitted
to the hospital for empirical antibiotic therapy if they are not
already inpatients.
O Low-risk patients have a MASCC score >21. Carefully selected
low-risk patients may be candidates for oral and/or outpatient
empirical antibiotic therapy.

6. Initial Empiric Antibiotic Therapy
O High risk: Monotherapy with an antipseudomonal b-
lactam agent, such as cefepime, a carbapenem
(meropenem or imipenem), or tazocin is
recommended.
O Other antimicrobials (aminoglycosides,
fluoroquinolones, and/or vancomycin) may be
added to the initial regimen for management of
complications (eg, hypotension and pneumonia) or
if antimicrobial resistance is suspected or proven

7. O Low risk: oral empirical Ciprofloxacin + Augmentin
O Other oral regimens that are commonly used:
 levofloxacin or ciprofloxacin monotherapy or
 ciprofloxacin + clindamycin
o Patients receiving fluoroquinolone prophylaxis
should not receive oral empirical therapy with a
fluoroquinolone.
o Hospital re-admission or continued stay in the
hospital is required for persistent fever or signs
and symptoms of worsening infection.

8. Modifications to initial
empirical therapy
O Unexplained persistent fever
O Documented susceptibility
O No evidence of certain infection e.g g+ve
O Hemodynamic unstability
O Simplify treatment in low risk
O Switching IV to oral
O Antifungal coverage

9. O i. MRSA: Consider early addition of
vancomycin, linezolid, or daptomycin.
O ii. VRE: Consider early addition of
linezolid or daptomycin.
O iii. ESBLs: Consider early use of a
carbapenem.
O iv. KPCs: Consider early use of
polymyxin-colistin or tigecycline.

10. Duration of empirical therapy
O In patients with clinically or
microbiologically documented infections,
the duration of therapy is dictated by the
particular organism and site; appropriate
antibiotics should continue for at least the
duration of neutropenia (until ANC is >
500 cells/mm3) or longer if clinically
necessary.

11. O In patients with unexplained fever, it is
recommended that the initial regimen be
continued until there are clear signs of
marrow recovery; the traditional endpoint
is an increasing ANC that exceeds 500
cells/mm3.

12. References
O UpToDate wesite
O IDSA guidelines