Management of fever in a neutropenic patient

Fever is common in patients with cancer. Although commonly caused by infection it can also be related to underlying malignancy, blood product transfusion, and pyrogenic medications. Careful evaluation of fever in a neutropenic patient should not take long. Untreated sepsis in a neutropenic patient can be rapidly fatal. Generally, antibiotics are administered after the following simple investigations:

♦ Blood cultures (peripheral and central, if line in situ)

♦ Sputum culture

♦ Urine analysis and culture

♦ Swabs from Hickman line exit site

♦ Careful physical examination

Treatment should then be instituted, with empirical antibiotic therapy, particularly if the patient is toxic or haemodynamically compromised. The widespread adoption of this approach has reduced the mortality of neutropenic sepsis to less than 10%.

Careful observation of the febrile response to antibiotics, coupled with body fluid culture results, will determine adjustment of antibiotic therapy over the next few days. If the fever is unremitting at 48 hours, or there is any clinical deterioration, an empirical change of antibiotics to a second-line antibiotic regime should be performed.

Failure to resolve the fever within 5 days may suggest other opportunistic infections such as fungi or parasites such as Pneumocystis carinii. Careful consideration of these diagnoses, in close consultation with a microbiologist, is required before initiation of specific treatments, such as amphotericin B, for these infections, since the therapies themselves are potentially toxic.

Often, resolution of neutropenia results in resolution of refractory fever. This process can be accelerated by the use of haemopoietic growth factors.

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