Manage febrile neutropenia

What about the best way to treat febrile neutropenia in cancer patients. These patients have an isolated temp of 38.5 (101.3 ℉) or higher OR a temp of  38 (100.4 ℉) or higher for at least an hour. PLUS an absolute neutrophil count (ANC) below 500 cells/mm3. Treat febrile neutropenia based on patient complication risks....

     LOW-risk patients can often be treated outpatient, but hospitalized patients are often HIGH-risk. These include patients expected to have an ANC under 100 cells/mm3 for more than a week, OR with comorbidities (hypotension, pneumonia, CNS changes, etc).

Antibiotics. In HIGH-risk patients, start with an IV broad-spectrum antipseudomonal beta-lactam, such as piperacillin/tazobactam (Tazocin), cefepime (Maxipime). Lean away from empiric MRSA coverage (vancomycin, linezolid) unless you suspect catheter infections, pneumonia, skin infections, etc. And discontinue vancomycin after 2 days if cultures remain negative.

Antifungals. Consider adding antifungals in high-risk patients if fever and neutropenia haven't resolved after 4 days of antibiotics AND no source is found. Lean toward echinocandins like caspofungin (Cancidas), lipid amphotericin B (Ambisome), or voriconazole (Vfend) based on your hospital's preference and efficacy seems similar. Continue antimicrobials based on culture results and infection site AND until ANC is at least 500 cells/mm3.

Colony-stimulating factors (CSFs). Most patients won't benefit from adding CSFs (Zarzio) to antimicrobials. But consider them in some cases like neutropenia expected for more than 10 days, sepsis, pneumonia, etc. CSFs (Zarzio) may shorten neutropenia by one day and hospital stay by two days. Don't increase the CSF (Zarzio) dose if it was started at home. Lean away from pegfilgrastim (Neulastim) due to cost. Plus each dose lasts 14 days, longer than needed for most hospitalized patients. Stop CSFs when ANC rises above 500 cells/mm3.

REFERENCES

• Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR; Infectious Diseases Society of America. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011 Feb 15;52(4):e56-93. Available at: https://academic.oup.com/cid/article/52/4/e56/382256?login=false

  Smith TJ, Bohlke K, Lyman GH, Carson KR, Crawford J, Cross SJ, Goldberg JM, Khatcheressian JL, Leighl NB, Perkins CL, Somlo G, Wade JL, Wozniak AJ, Armitage JO; American Society of Clinical Oncology. Recommendations for the Use of WBC Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2015 Oct 1;33(28):3199-212. Available at: https://ascopubs.org/doi/10.1200/JCO.2015.62.3488