#20 Neutropenic Fever

Neutropenic fever is a common hospital presentation for oncology patients. Dr. Darien Reed explains what neutropenic fever is, who is at risk for getting it, important assessment findings, and how we work up these patients.

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What is neutropenic fever?

Febrile neutropenia is defined as a one-time oral temperature of greater than 38.3°C (approximately 100.9°F) or a sustained temperature of greater than 38°C (100.4°F) for ≥ 1 hour in a patient who has an absolute neutrophil count of less than 500 cells/μL or an absolute neutrophil count expected to decrease to less than 500 cells/μL within a 48-hour period (Journal of Oncology Practice).

Who is at risk for developing febrile neutropenia?

  • Patients undergoing conditioning therapy or chemotherapy for hematologic malignancies (i.e. leukemias, myelomas, lymphomas) are, by far, at highest risk due to the prolonged neutropenia that can last up at 14 days.
  • Patients receiving chemotherapy for solid organ tumors are also at risk, but have a lower rates of febrile neutropenia than hematologic malignancies to a period of neutropenia that lasts less than 7 days.
  • Patients receiving medications such as anti-epileptics, PPIs
  • Patients with severe autoimmune diseases such as lupus, rheumatoid arthritis (specifically with Felty Syndrome)
Wall chart documenting the WBC, hemoglobin, and platelet count for a patient undergoing conditioning and stem cell transplant.

Common Sites of Infection

  • Along the alimentary tract: oral cavity, esophagus, colon and rectum is the most common source of infection in neutropenic patients.
    • Breaches in mucosal barriers accompanying intense chemotherapeutic regimens, allow members of the indigenous flora to enter the bloodstream
  • Respiratory tract: sinus and lungs
  • Skin, including catheter sites (antimicrobe.org)

Management Guidelines

Assessment highlights

  • Thorough skin exam, including the peri-rectal area
  • Oral mucosa
  • Respiratory
  • Neurologic Dr. Reed stresses the importance of an accurate a thorough documentation of the patient’s neurologic status. This provides a basis of comparison for following providers.

standard initial orders for all patients with febrile neutropenia

  • CBC, lactate, blood cultures
  • Chest imaging (x-ray or CT)
  • Urinalysis and culture
  • Empiric antibiotics: Cefepime, Piperacillin/Tazobactam