Episode 928: Neutropenic Fever

Contributor: Taylor Lynch, MD

Educational Pearls:

What is neutropenic fever?

• Specific type of fever that is seen in cancer patients and other patients with impaired immune systems

• These patients are highly susceptible to infection

• Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest

• It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever

• To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.

• The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.

• Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning

What is the workup and treatment?

• Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.

• Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.

• Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.

• Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

References

1. Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863

2. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3