Provide systemic antimicrobial therapyfor neutropenic patients with fever
Provide systemic antimicrobial therapyfor neutropenic patients with fever: Excerpt from Avoiding Common Pediatric Errors
Author: Emily Riehm Meier, MD
What to Do - Take Action
Febrile neutropenia should be considered a medical emergency in children
receiving chemotherapy. Neutropenia is defined as an absolute neutrophil
count (total white blood cell count in thousands multiplied by the fraction of segmented neutrophils and bands) <500/µL or an absolute neutrophil count <1,000/µL and falling. Blood counts are expected to nadir
7 to 10 days following chemotherapy. Fever is defined as an oral temperature
>38.5°C, an axillary temperature >37.5°C or three low-grade temperatures
(38.0°–8.4°C orally or 37.0°–37.4°C axillary) in 24 hours. Rectal temperatures should not be taken in neutropenic patients due to the increased risk
of infection from gastrointestinal flora. Febrile patients who have recently
received chemotherapy should be considered at high risk of infection due to
their immunocompromised state and receive intravenous antibiotics within
1 hour of presenting to the emergency department.
Evaluation of a patient with fever and suspected neutropenia should
include careful history and physical examination, keeping in mind that due
to the lack of neutrophils, the erythema, suppuration, and edema that commonly accompany infections may be lacking. For example, a patient who
has exquisite tenderness over a central line site without concomitant erythema, edema, or suppurative drainage should still be treated for cellulitis.
The same can be said for patients with respiratory symptoms without infiltrate on chest x-ray or urinary symptoms without pyuria. Laboratory
evaluation should include complete blood count, creatinine, and liver enzymes (to use as a baseline when monitoring for antibiotic/antifungal
toxicity), and blood cultures. Some debate exists if a peripheral culture should be collected in addition to cultures from the patient's central line. Aerobic, anaerobic, and fungal cultures should be collected
from all sites (including each lumen of the central line). Urinalysis and
chest x-ray are not indicated unless the patient has significant symptomatology.
Treatment of febrile neutropenia should be based on the bacteria most
likely to cause infection in neutropenic patients (Table 178.1 ) and susceptibility profiles at individual institutions. Although gram-positive organisms
causebacteremiamorefrequentlythangram-negativeorganisms,monotherapy with a third-or fourth-generation cephalosporin with antipseudomonal
coverage (ceftazidime or cefepime) or a carbapenem (meropenem) is adequate coverage in most uncomplicated cases of febrile neutropenia. Bacteremia only accounts for 15% to 20% of documented infections in febrile
neutropenic patients. Other sites of infection include the gastrointestinal,
urinary, or respiratory tracts, where infection with gram-negative organisms
is much more common. Therefore, vancomycin is not indicated for treatment of febrile neutropenia in all patients; its use should be reserved for
patients considered high risk (Table 178.2 ).
Table 178.1 Most Common Organisms Causing Bacteremia in Febrile Neutropenic Patients
• Staphylococci
• Methicillin-resistant Staphylococcus aureus
• Pseudomonas aeruginosa
• Enterococci
• Escherichia coli
• Klebsiella species
Vancomycinreducesmortalityfrom Streptococcusviridans whengiven as
initialtreatment(inconjunctionwithananti-pseudomonalagent)inpatients
at high risk for S. viridans infections (those who have received high-dose cytarabine chemotherapy). Vancomycin may be discontinued after 48 hours of
treatment if there is no evidence of S. viridans or other gram-positive bacteremia. Initial therapy with an antifungal is not warranted because fungal
infections usually occur after prolonged neutropenia. If a patient is persistently febrile and neutropenic >5 days of broad-spectrum antibiotics,
antifungal coverage should be added.
Table 178.2 Indications for Initial Use of Vancomycin in Febrile Neutropenia
• Suspected catheter infection
• Unstable clinical appearance (hypotension, etc.)
• Known colonization with organisms sensitive only to vancomycin
(methicillin-resistant Staphylococcus aureus)
• Positive blood culture with gram-positive organism, pending identification and
susceptibility testing
• Patients at high risk of Streptococcus viridans bacteremia, based on type of
chemotherapy most recently given
Suggested Readings
Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents
in neutropenic patients with cancer. Clin Infect Dis. 2002;34:730–761.
Kanamaru A, Tatsumi Y. Microbiological data for patients with febrile neutropenia. Clin Infect
Dis. 2004;39(Suppl 1):S7–S10.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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Remember the contraindications to diphtheria, pertussis, and tetanus (DPT) immunizations and usealternatives recommended by the American Academy of Pediatrics (AAP) and the U.S. Public Health Service (Avoiding Common Pediatric Errors)
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