Febrile Neutropenia. Mervat Hesham 2009. Febrile Neutropenia. Who should receive empirical Rx? When should empirical Rx be started? What is appropriate initial Rx? How should initial Rx be modified? How long should empirical Rx be continued?. Febrile neutropenia. *Fever
Single oral temperature > 38.3ºC
mild 1.0 to 1.5 x 103/l
moderate 0.5 to 1.0 x 103/l
Severe <0.5 x 103/l
no identifiable etiology i.e fever of unknown
fever and neutrpenia,
Gram positive bacteremia 70%
Gram negative bacteremia 30%
Gram positive organisms
Gram negative organisms
Attempt to reduce acquisition of resistant hospital pathogens in neutropenic patients by using the following precautions:
(cycle/course of chemotherapy,prophylactic agents, corticosteroids , immunosuppresive agents,previous infections or procedures).
*Signs(perianal erythema and tenderness, Minimal erythema or serous discharge at the site of a Hickman catheter, Signs & Symptoms of Sepsis (any one or more of the following signs):
1. Hyperpyrexia (Temperature > 104oF).
2. Hypothermia (< 96oF).
3. Chills not associated with transfusions or drugs
4. Hypotension (BP change > 30% or SPB < 90 mmHg; refer to age specific guidelines for children).
5. Hypoxemia (O2 saturation < 90% or > 5% change from baseline).
6. Moderate/severe End Organ Dysfunction (increased Scr or LFTs).
7. Altered Mental Status.
-White cells, haemoglobin, platelets
-Electrolytes, urea, creatinine, Liver function
-Blood cultures (peripheral and all central line lumens)
-Exit site swabs
-Urine analysis and culture.
-Stool analysis and culture.
-+/- Cerebrospinal fluid
Baseline chest X-ray and any other X-ray indicated by exam. -+/- CT abdo/pelvis
Empiric antibiotic therapy Broad spectrum empiric antibiotic therapy must be started properly prior to organism identification.
Survival is greater than 90% when patients are treated with appropriate empiric therapy.
* Esophagitis , localized pulmonary infiltrate.
* Failure of treatment of diffuse pulmonary infiltrate by I.V TMP and erythromycin .
* Sinus tenderness or nasal ulcerative lesion.
Supportive measures in febrile neutropenia
Colony Stimulating factors
(a) Patients already on growth factors should continue on therapy if febrile neutropenia develops. There is no rationale to increase the dose.
(b) Patients not on a growth factor should not be started unless certain prognostic factors predictive of clinical deterioration are present, including signs/symptoms of sepsis, pneumonia, or fungal infection.
(c) Do NOT give growth factors if the patient is receiving concurrent radiation therapy – a more prolonged neutropenia may result.
* I/V Piperacillin 200-300mg/kg/daily
( IV Divided q4–6h)
*I/V Ticarcillin 300mg/kg/daily
( IV Divided q4–6h)
*I/V Gentamicin 6.0–7.5 mg/kg/daily.
(Loaded with 2mg/kg IV Divided q8h)
*I/V Amikacin 7.5mg/kg/12 hourly
( 15 mg/kg/day IV Divided q8h)
shown to be as effective as combination antibiotic
regimen for empiric therapy.
• Ceftazidime (3rd generation cephalosporin)( Fortum )
100–150 mg/kg/day IV Divided q8h
• Imipenam-cilastatin ( carbepenam )
I/V 12.5mg/kg/6 hourly
Meropenem 0–120 mg/kg/day IV Divided q8h
( maximum dose 6 g/day)
• Cefepime (4th generation cephalosporin) ( Maxipim)
50 mg/kg per dose IV Divided q8h
or I/V 1-2gm/ 8 hourly
• Oral ciprofloxacin 750mg/8 hourly plus
IV Test dose 0.1 mg/kg to a
maximum dose of 1 mg over 1 hour; if tolerated, may use 0.4 mg/kg and increase to 1 mg/kg/day
IV, PO 6 mg/kg every 12 hours, IV for first 24 hours and then 4 mg/kg every 12 hours.
>40kg, 200 mg bid, may increase to 300 mg bid,
<40 kg 100 mg bid, may increase to 150 mg bid
IV, PO 2 mg/kg/day (maximum dose 600 mg/day)
( I/V or oral fluconazole 200mg loading dose then 100mg/daily for 10-14 days for candidiasis)
*IV For children <1 year of age:
30 mg/kg/day in 3 divided doses for 7–10 days; some
* IV For children >1 year of age: 1500 mg/m2 of body surface area per day in 3 divided doses for 7–10 days.
1- Acquired CMV retinitis in immunocompromised Host
*IV 10 mg/kg/day in 2 divided
doses for 14–21 days;
*For long-term suppression, 5 mg/kg/day
for 5–7 days/week.
2- Prophylaxis of CMV inhigh-risk host:
IV 10 mg/kg/day in 2 divideddoses for 1 wk, then 5 mg/kg/day in 1 dose for 100 days.
30 mg/kg/day IV (divided q6h)
(loading dose initially 15 mg/kg)
40 mg/kg/day(maximum 2 g/day)
IV Divided q6–8h
40 mg/kg/day IV Divided q6–8h