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| {| class="infobox" style="float: right;" | | {{Siren|Febrile neutropenia}} |
| | style="vertical-align: middle; padding: 5px;" align=center | [[File:Siren.gif|30px|link=Febrile neutropenia resident survival guide]]
| | {{Febrile neutropenia}} |
| | style="vertical-align: middle; padding: 5px;" align=center | [[Febrile neutropenia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| {{SI}} | |
| {{CMG}} | | {{CMG}} |
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| {{SK}} F and N; fever and neutropenia; FN; neutropenic fever; neutropenic fever syndrome | | {{SK}} F and N; fever and neutropenia; FN; hot and low; hot leuk; neutropenic fever; neutropenic fever syndrome; neutropenic sepsis |
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| == Overview == | | ==[[Febrile neutropenia overview|Overview]]== |
| '''Febrile neutropenia''' is a condition characterized by a decrease in neutrophils (neutropenia) associated with fever, the latter indicating the presence of an infection.<ref>{{Cite web | title = NCI Thesaurus | accessdate = | url = http://ncit.nci.nih.gov/ncitbrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C35665&ns=NCI_Thesaurus }}</ref> Most patients will have no infectious etiology documented; clinically defined infections occur in 20%–30% of febrile episodes.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>
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| == Historical Perspective == | | ==[[Febrile neutropenia historical perspective|Historical Perspective]]== |
| In 1966, Bodey ''et al.'' first described the quantitative association between leukocyte counts and the incidence of infection in a study of acute leukemia which demonstrated that the risk and the type of infection are related to the severity and duration of granulocytopenia.<ref>{{Cite journal | issn = 0003-4819 | volume = 64 | issue = 2 | pages = 328–340 | last = Bodey | first = G. P. | coauthors = M. Buckley, Y. S. Sathe, E. J. Freireich | title = Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia | journal = Annals of Internal Medicine | date = 1966-02 | pmid = 5216294 }}</ref> Infection risk begins to increase when the absolute neutrophil count (ANC) decreases to less than 1000 cells/mm<sup>3</sup> and rises markedly when the ANC drops to less than 500 cells/mm<sup>3</sup>. When the causative pathogen is identifiable, bacterial or viral etiology predominates within the first seven days of neutropenic fever, while infection with antibiotic-resistant bacteria or invasive fungi occurs more often in the setting of protracted neutropenia.<ref>{{Cite journal | issn = 0025-7974 | volume = 61 | issue = 3 | pages = 153–165 | last = Pizzo | first = P. A. | coauthors = K. J. Robichaud, R. Wesley, J. R. Commers | title = Fever in the pediatric and young adult patient with cancer. A prospective study of 1001 episodes | journal = Medicine | date = 1982-05 | pmid = 7078399 }}</ref>
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| == Pathophysiology == | | ==[[Febrile neutropenia pathophysiology|Pathophysiology]]== |
| A number of factors pose an increased risk for infection in patients with neutropenic fever:
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| * '''Absolute or functional leukopenia'''
| | ==[[Febrile neutropenia causes|Causes]]== |
| :: [[Leukocytes]], particularly [[neutrophils]], constitute one of the front-line defense mechanisms against invading [[microorganisms]]. [[Chemotherapy]] is associated with both qualitative and quantitative deficits in circulating neutrophils by lowering neutrophil counts and impairing [[chemotaxis]] and [[phagocytosis]], respectively. In addition, patients receiving [[glucocorticoid]]-containing regimens, [[calcineurin]] inhibitors, or [[fludarabine]] are also predisposed to infection as a consequence of lymphocyte dysfunction.
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| * '''Altered microbiota'''
| | ==[[Febrile neutropenia epidemiology and demographics|Epidemiology and Demographics]]== |
| :: [[Microbiome|Microbiota]] that inhabit the skin, respiratory tract, and digestive tract may be altered by cancer and its treatment or the use of antibiotics.<ref>{{Cite journal | doi = 10.1056/NEJMct1210890 | issn = 1533-4406 | volume = 368 | issue = 12 | pages = 1131–1139 | last = Bennett | first = Charles L. | coauthors = Benjamin Djulbegovic, LeAnn B. Norris, James O. Armitage | title = Colony-stimulating factors for febrile neutropenia during cancer therapy | journal = The New England Journal of Medicine | date = 2013-03-21 | pmid = 23514290 | pmc = PMC3947590 }}</ref>
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| * '''Breaches of natural barriers'''
| | ==[[Febrile neutropenia risk factors|Risk Factors]]== |
| :: [[Mucositis]] may occur as a direct adverse effect of [[chemotherapy]] or [[radiotherapy]] and disrupt the barrier function of the endothelial lining. Indwelling catheters and implanted devices allow access of skin [[commensal]]s into blood or subcutaneous tissues or serve as a [[biofilm]] which bacteria can colonize.
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| * '''Immune defects associated with specific primary malignancies'''
| | ==[[Febrile neutropenia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| :: An increased risk of infection has been observed in patients with [[Hodgkin's lymphoma]] (as a result of defects in [[cell-mediated immunity]]) and in patients with [[chronic lymphocytic leukemia]] or [[multiple myeloma]] (as a result of [[hypogammaglobulinemia]]).
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| == Causes == | | ==Diagnosis== |
| {| style="float: right; width: 400px;"
| | [[Febrile neutropenia diagnostic criteria|Diagnostic Criteria]] | [[Febrile neutropenia initial assessment|Initial Assessment]] | [[Febrile neutropenia history and symptoms|History and Symptoms]] | [[Febrile neutropenia physical examination|Physical Examination]] | [[Febrile neutropenia laboratory findings|Laboratory Findings]] | [[Febrile neutropenia CT|CT]] | [[Febrile neutropenia other diagnostic studies|Other Diagnostic Studies]] |
| ! style="font-size: 85%; background: #545454; color: #F8F8FF;" | Common Bacterial Pathogens in Neutropenic Patients<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>
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| ! style="font-size: 85%; background: #DCDCDC;" | Gram-Positive Pathogens
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| :* Coagulase-negative staphylococci
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| :* Staphylococcus aureus, including methicillin-resistant strains
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| :* Enterococcus species, including vancomycin-resistant strains
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| :* Viridans group streptococci
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| :* Streptococcus pneumoniae
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| :* Streptococcus pyogenes
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| ! style="font-size: 85%; background: #DCDCDC;" | Gram-Negative Pathogens
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| :* Escherichia coli
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| :* Klebsiella species
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| :* Enterobacter species
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| :* Pseudomonas aeruginosa
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| :* Citrobacter species
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| :* Acinetobacter species
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| :* Stenotrophomonas maltophilia
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| Bloodstream infections caused by endogenous flora and reactivation of latent infections account for a majority of initial febrile episode in neutropenic patients with cancer. Common bacterial isolates that cause bacteremia in the setting of neutropenia are listed in the table.<ref>{{Cite journal | doi = 10.1007/s00277-011-1373-2 | issn = 1432-0584 | volume = 91 | issue = 5 | pages = 767–774 | last = Pagano | first = L. | coauthors = M. Caira, G. Rossi, M. Tumbarello, R. Fanci, M. G. Garzia, N. Vianelli, N. Filardi, P. De Fabritiis, A. Beltrame, M. Musso, A. Piccin, A. Cuneo, C. Cattaneo, T. Aloisi, M. Riva, G. Rossi, U. Salvadori, M. Brugiatelli, S. Sannicolò, M. Morselli, A. Bonini, P. Viale, A. Nosari, F. Aversa, Hema e-Chart Group, Italy | title = A prospective survey of febrile events in hematological malignancies | journal = Annals of Hematology | date = 2012-05 | pmid = 22124621 }}</ref> Certain endogenous microorganisms may be reactivated and exit latency during immunosuppression. These include herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis B and C viruses, and Mycobacterium tuberculosis. Exogenous pathogens carried by contaminated blood products, medical equipment and devices, water sources, and health care workers represent less common sources of infection. These include Clostridium difficile, respiratory syncytial virus, vancomycin-resistant enterococci, and other multiresistant bacteria.<ref>{{Cite book | edition = 5 edition | publisher = Saunders | isbn = 9781455728657 | last = MD | first = John E. Niederhuber | coauthors = James O. Armitage MD, James H. Doroshow MD, Michael B. Kastan MD PhD, Joel E. Tepper MD | title = Abeloff's Clinical Oncology: Expert Consult Premium Edition - Enhanced Online Features and Print, 5e | location = Philadelphia, Pennsylvania | date = 2013-11-05 }}</ref>
| | == Treatment == |
| | [[Febrile neutropenia medical therapy|Medical Therapy]] | [[Febrile neutropenia primary prevention|Primary Prevention]] |
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| Fungal infections often take place in the setting of prolonged or profound neutropenia after administration of empirical therapy. Candidiasis may range in severity from mucosal or cutaneous infection to septicemia, endocarditis, or disseminated infection. Aspergillus, on the contrary, typically causes life-threatening infection of the sinuses and lungs, particularly after protracted neutropenia.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>
| | == Guideline Sources == |
| | * Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref> |
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| == Epidemiology and Demographics ==
| | * Antimicrobial Prophylaxis and Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology Clinical Practice Guideline<ref>{{Cite journal | doi = 10.1200/JCO.2012.45.8661 | issn = 1527-7755 | volume = 31 | issue = 6 | pages = 794–810 | last = Flowers | first = Christopher R. | coauthors = Jerome Seidenfeld, Eric J. Bow, Clare Karten, Charise Gleason, Douglas K. Hawley, Nicole M. Kuderer, Amelia A. Langston, Kieren A. Marr, Kenneth V. I. Rolston, Scott D. Ramsey | title = Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline | journal = Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology | date = 2013-02-20 | pmid = 23319691 }}</ref> |
| Approximately 10% to 50% of patients with solid tumors and more than 80% of those with hematologic malignancies will develop fever during courses of cytotoxic chemotherapy. However, an infectious etiology can be established in a minority of patients, and clinically defined infections occur in 20% to 30% of febrile episodes.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>
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| Over the past few decades, there has been a shift in the spectrum of bacterial isolates from patients with febrile neutropenia. Gram-negative organisms prevailed in the era when cytotoxic chemotherapy was initially introduced, whereas Gram-positive skin flora including coagulase-negative staphylococci evolved as the most common isolates after widespread use of indwelling catheters and prophylactic antibiotics. In addition, there has been a drift in susceptibility patterns, with resistance seen in the general population of hospitalized patients now emerging in febrile neutropenic patients.<ref>{{Cite journal | doi = 10.1086/383048 | issn = 1537-6591 | volume = 39 Suppl 1 | pages = –25-31 | last = Ramphal | first = Reuben | title = Changes in the etiology of bacteremia in febrile neutropenic patients and the susceptibilities of the currently isolated pathogens | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2004-07-15 | pmid = 15250017 }}</ref>
| | * Guideline for the Management of Fever and Neutropenia in Children with Cancer and/or Undergoing Hematopoietic Stem-Cell Transplantation: American Society of Clinical Oncology Endorsement<ref>{{Cite journal | doi = 10.1200/JCO.2012.42.7161 | issn = 1527-7755 | volume = 30 | issue = 35 | pages = 4427–4438 | last = Lehrnbecher | first = Thomas | coauthors = Robert Phillips, Sarah Alexander, Frank Alvaro, Fabianne Carlesse, Brian Fisher, Hana Hakim, Maria Santolaya, Elio Castagnola, Bonnie L. Davis, L. Lee Dupuis, Faith Gibson, Andreas H. Groll, Aditya Gaur, Ajay Gupta, Rejin Kebudi, Sérgio Petrilli, William J. Steinbach, Milena Villarroel, Theoklis Zaoutis, Lillian Sung, International Pediatric Fever and Neutropenia Guideline Panel | title = Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation | journal = Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology | date = 2012-12-10 | pmid = 22987086 }}</ref> |
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| == Risk Factors == | | * Prevention and Treatment of Cancer-Related Infections: National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology<ref>{{Cite web | title = Prevention and Treatment of Cancer-Related Infections | accessdate = | url = http://www.nccn.org/professionals/physician_gls/PDF/infections.pdf }}</ref> |
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| == Natural History, Complications and Prognosis == | | * Management of Febrile Neutropenia: European Society for Medical Oncology Clinical Recommendations<ref>{{Cite journal | doi = 10.1093/annonc/mdp163 | issn = 1569-8041 | volume = 20 Suppl 4 | pages = 166–169 | last = Marti | first = F. Marti | coauthors = M. H. Cullen, F. Roila, ESMO Guidelines Working Group | title = Management of febrile neutropenia: ESMO clinical recommendations | journal = Annals of oncology: official journal of the European Society for Medical Oncology / ESMO | date = 2009-05 | pmid = 19454445 }}</ref> |
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| | == References == |
| | {{reflist|2}} |
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| | | == Related Chapters == |
| == Diagnosis == | | *[[Chemotherapy]] |
| === Diagnostic Criteria ===
| | *[[Fever]] |
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| The definitions of [[fever]] and [[neutropenia]] are used to identify patients in whom empirical antibiotic therapy must be initiated. However, neutropenic patients represent a heterogeneous population and treatment may be considered even when they do not meet these specific criteria. Clinical judgment based on parameters in risk assessment also plays a critical role in tailoring the management.
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| {{cquote|
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| ==== Fever ====
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| Fever is defined as a single oral temperature measurement of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) sustained over a 1-hour period.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>}}
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| {{cquote|
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| ==== Neutropenia ====
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| Neutropenia is defined as an absolute neutrophil count (ANC) of <500 cells/mm<sup>3</sup> or an ANC that is expected to decrease to <500 cells/mm<sup>3</sup> during the next 48 hours.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>}}
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| {{cquote|
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| ==== Profound neutropenia ====
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| Neutropenia in which the ANC is <100 cells/mm<sup>3</sup>; a manual reading of the blood smear is required to confirm this degree of neutropenia.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>}}
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| {{cquote|
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| ==== Functional neutropenia ====
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| Functional neutropenia refers to patients whose hematologic malignancy results in qualitative defects (impaired [[phagocytosis]] and killing of pathogens) of circulating neutrophils. These patients should also be considered to be at increased risk for infection, despite a normal neutrophil count.<ref>{{Cite journal | doi = 10.1093/cid/ciq147 | issn = 1537-6591 | volume = 52 | issue = 4 | pages = 427–431 | last = Freifeld | first = Alison G. | coauthors = Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard, null Infectious Diseases Society of Americaa | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America | journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America | date = 2011-02-15 | pmid = 21205990 }}</ref>}}
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| {{cquote|
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| ==== Microbiologically defined infection ====
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| This can include both
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| # bacteremia, either with a single organism or polymicrobial infection, but without a definable nonhematogenous site of infection, and
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| # a microbiologically defined site of infection (e.g., pneumonia, cellulitis) with or without concomitant bacteremia.<ref>{{Cite journal | issn = 0022-1899 | volume = 161 | issue = 3 | pages = 397–401 | title = From the Immunocompromised Host Society. The design, analysis, and reporting of clinical trials on the empirical antibiotic management of the neutropenic patient. Report of a consensus panel | journal = The Journal of Infectious Diseases | date = 1990-03 | pmid = 2179421 }}</ref>}}
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| {{cquote|
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| ==== Clinically defined infection ====
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| This is designated when a site of infection is diagnosed (e.g., pneumonia,cellulitis) but its microbiologic pathogenesis either cannot be proven or is inaccessible to examination.<ref>{{Cite journal | issn = 0022-1899 | volume = 161 | issue = 3 | pages = 397–401 | title = From the Immunocompromised Host Society. The design, analysis, and reporting of clinical trials on the empirical antibiotic management of the neutropenic patient. Report of a consensus panel | journal = The Journal of Infectious Diseases | date = 1990-03 | pmid = 2179421 }}</ref>}}
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| {{cquote|
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| ==== Unexplained fever ====
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| In the neutropenic patient, this is defined as a new fever that is not accompanied by either clinical or microbiologic evidence of infection.<ref>{{Cite journal | issn = 0022-1899 | volume = 161 | issue = 3 | pages = 397–401 | title = From the Immunocompromised Host Society. The design, analysis, and reporting of clinical trials on the empirical antibiotic management of the neutropenic patient. Report of a consensus panel | journal = The Journal of Infectious Diseases | date = 1990-03 | pmid = 2179421 }}</ref>}}
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| === History ===
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| === Symptoms ===
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| === Physical Examination ===
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| === Laboratory Findings ===
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| == Multinational Association for Supportive Care in Cancer (MASCC) Risk Index ==
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| The Multinational Association for Supportive Care in Cancer (MASCC) Risk Index can be used to identify high-risk patients (score <21) and low-risk patients (score ≥21 points) for serious complications of febrile neutropenia (including death, [[intensive care unit]] admission, confusion, cardiac complications, [[respiratory failure]], [[renal failure]], [[hypotension]], [[bleeding]], and other serious medical complications).<ref name="pmid10944139">{{cite journal |author=Klastersky J, Paesmans M, Rubenstein EB, ''et al.'' |title=The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients.|journal= J Clin Oncol. |volume=18 |issue=16 |pages=3038–51 |date=16 August 2000|pmid=10944139| url=http://jco.ascopubs.org/cgi/content/full/18/16/3038 |issn=0732-183X}}</ref> The score was developed to select patients for therapeutic strategies that could potentially be more convenient or cost-effective. The various variables and the weight of individual variables used in the MASCC risk index is as follows. To summarize, risk assessment helps determining the type of empirical antibiotic therapy, venue of the treatment, and duration of the antibiotic therapy.
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| {|class="wikitable"
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| ! Characteristic!! Score
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| | No or mild symptoms in patients following an episode of febrile neutropenia || 5
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| | Absence of hypotension with a systolic blood pressure >90 mmHg || 5
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| | No chronic obstructive pulmonary disease (active chronic bronchitis, emphysema, decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or bronchodilators) || 4
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| | Solid tumor or hematologic malignancy with no previously demonstrated fungal infection or empirically treated suspected fungal infection|| 4
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| | Absence of dehydration that requires parenteral fluids|| 3
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| | Moderate symptoms in patients following an episode of febrile neutropenia|| 3
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| | Outpatient status|| 3
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| | Age <60 years|| 2
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| A prospective trial demonstrated that a modified MASCC score can identify patients with febrile neutropenia at low risk of complications as well.<ref name="pmid17960431">{{cite journal |author=de Souza Viana L, Serufo JC, da Costa Rocha MO, Costa RN, Duarte RC |title=Performance of a modified MASCC index score for identifying low-risk febrile neutropenic cancer patients |journal=Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer |volume=16 |issue=7 |pages=841–6 |year=2008 |month=July |pmid=17960431 |doi=10.1007/s00520-007-0347-3 |issn=0941-4355}}</ref>
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| == Treatment ==
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| Generally, patients with febrile neutropenia are treated with empirical [[antibiotic]]s until the neutrophil count has recovered (Absolute neutrophil counts greater than 500/mm3) and the fever has abated; if the neutrophil count does not improve, treatment may need to continue for two weeks or occasionally more. In cases of recurrent or persistent fever, an antifungal agent should be added.
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| Guidelines issued in 2002 by the [[Infectious Diseases Society of America]] recommend the use of particular combinations of antibiotics in specific settings; mild low-risk cases may be treated with a combination of oral [[co-amoxiclav]] and [[ciprofloxacin]], while more severe cases require [[cephalosporin]]s with activity against ''[[Pseudomonas aeruginosa]]'' (e.g. [[cefepime]]), or [[carbapenem]]s ([[imipenem]] or [[meropenem]]). A subsequent [[meta-analysis]] published in 2006 found that [[cefepime]] was associated with more negative outcomes, and that carbapenems (while causing a higher rate of [[pseudomembranous colitis]]) were the most straightforward in use.<ref name="pmid16344285">{{cite journal |author=Paul M, Yahav D, Fraser A, Leibovici L |title=Empirical antibiotic monotherapy for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials |journal=J. Antimicrob. Chemother. |volume=57 |issue=2 |pages=176–89 |year=2006 |pmid=16344285 |doi=10.1093/jac/dki448|url=http://jac.oxfordjournals.org/cgi/content/full/57/2/176 |month= February|issn=0305-7453}}</ref>
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| In 2010, an updated guidelines was issued by the [[Infectious Diseases Society of America]], recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), piperacillin/tazobactam for high risk patients and [[co-amoxiclav]] and [[ciprofloxacin]] for low risk patients. Patients who do not strictly fulfill the criteria of 'low risk patients' should be admitted to the hospital and treat as high risk patients.
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| == See Also ==
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| *[[Neutropenia]] | |
| *[[Leukopenia]] | | *[[Leukopenia]] |
| *[[Fever]]
| |
| *[[Myelosuppression]] | | *[[Myelosuppression]] |
| *[[Chemotherapy]] | | *[[Neutropenia]] |
| | |
| ==References==
| |
| {{Reflist|2}}
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| ==External Links== | | == External Links == |
| * [http://www.cancer.gov/dictionary?CdrID=415543 Febrile neutropenia] entry in the NCI Dictionary of Cancer Terms | | * [http://www.cancer.gov/dictionary?CdrID=415543 Febrile neutropenia entry in the NCI Dictionary of Cancer Terms] |
