As a clinical pharmacist, you should act fast when treating febrile neutropenia. Febrile neutropenia in patients with cancer is a medical emergency, since delays in care are linked to increased mortality. These patients have an isolated temp of 101°F or higher OR a temp of 100.4°F or higher for at least an hour. PLUS, an absolute neutrophil count (ANC) currently below 500 cells/mm³ or expected to be within 48 hrs.
Treat febrile neutropenia based on risk of complications. For example, HIGH-risk is based on factors such as an expected ANC under 100 cells/mm³ for more than a week, or signs of a complex infection (hypotension, CNS changes, etc) Or consider assessing risk with a tool (MASCC risk index, etc).
Antibiotics. Begin antibiotics within 1 hour of triage. Start an IV broad-spectrum antipseudomonal beta-lactam (cefepime, etc) while determining risk. Expect low-risk patients to be discharged home from the ED on oral agents, usually ciprofloxacin plus amoxicillin/clavulanate. For high-risk patients, continue inpatient IV antibiotics. Don’t empirically add MRSA coverage (vancomycin, etc). But consider for suspected serious gram-positive infections (catheter, pneumonia, etc) or hemodynamic instability. Stop MRSA coverage after 2 days if cultures remain negative. Consider a flag in patient’s document to review after 48 hours. If there’s no clear infectious source, generally stop empiric coverage when fever resolves and ANC is at least 500 cells/mm³.
Antifungals. Consider adding antifungals in high-risk patients if fever and neutropenia haven’t resolved or recur after 4 to 7 days of antibiotics AND no source is found. Or add sooner in hemodynamically unstable patients. Lean toward an echinocandin (caspofungin, etc) or voriconazole over amphotericin B, due to its side effects.
Colony-stimulating factors (CSFs). Continue home CSFs (filgrastim, etc), but don’t increase the dose. It’s okay to switch to your formulary CSF. But if a patient takes pegfilgrastim, wait until about 14 days after their last dose. Limit new starts to complicated cases (sepsis, etc). In these patients, CSFs may shorten neutropenia by 1 day and hospital stay by 2 days. Stop when ANC rises above 500 cells/mm³.
REFERENCES
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Nccn.org. [online] Available at: https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf
Taplitz RA, Kennedy EB, Bow EJ, Crews J, Gleason C, Hawley DK, Langston AA, Nastoupil LJ, Rajotte M, Rolston K, Strasfeld L, Flowers CR. Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. J Clin Oncol. 2018 May 10;36(14):1443-1453. Available at: https://ascopubs.org/doi/10.1200/JCO.2017.77.6211
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
Nccn.org. [online] Available at: https://www.nccn.org/professionals/physician_gls/pdf/growthfactors.pdf