Treatment

In any severely neutropenic patient it is essential to start treatment empirically with an antibiotic regimen that is bactericidal and has a broad spectrum of activity, particularly against the more virulent Gram-negative bacteria such as Ps. aeruginosa. There is no time to wait for the results of cultures as delay in the commencement of antibiotics is associated with an extremely high mortality. The initial clinical manifestation of any infectious process is usually fever. Fever suggestive of infection is defined as an elevation of core body temperature in excess of 38 °C on two occasions in 24 h or 38.5 °C on one occasion in the absence of any obvious non-infectious cause of fever (e.g. blood transfusion). Such a definition is designed to prompt immediate clinical evaluation and early empirical antimicrobial therapy, but the absence of a fever or the presence of hypothermia does not exclude an infective process.

It is not possible to discern on clinical grounds alone the difference between infectious fever and fever secondary to a neoplasm, drug reaction, or hypersensitivity reaction (including reactions to blood products). The basic tenet that underlies all major initial therapeutic choices should be the clinical status of the patient. If the patient's immune status is severely impaired, as manifested by a circulating normal neutrophil count of less than 0.5 * 10 9/l, or the clinical state appears to be deteriorating, it is prudent to obtain the cultures mentioned above and begin empirical antimicrobial treatment. If the neutrophil count is greater than 0.5 * 10 9/l and there is a reasonable likelihood that the fever is due to a hypersensitivity reaction or underlying disease, then diagnostic measures including cultures should be obtained and the patient observed very carefully over the ensuing hours.

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