Neutropenic Fever

Neutropenia is an absolute neutrophil count (ANC) <1500, severe neutropenia is an ANC < 500 cells/microL.

Scenario: A patient who recently had chemotherapy started having fever a few days after getting chemotherapy.

EMS: If patient becomes very sick and has fever and weakness, patient may come to ER via EMS who then may give iv fluids if hypotensive.

ER:

Routine labs, Chest x ray, EKG, Lactic acid

Blood cultures X2

Urinalysis

Viral RT-PCR to rule out COVID 19, or other viral infections.

Give Empiric broad spectrum antibiotics with in 30-60min as fever in a neutropenic patient is considered a medical emergency.

Hospitalist:

Admit to Telemetry floor as inpatient.

Neutropenic precautions

Continue IV antibiotics- Cefepime 2 g IV every 8 hrs or Meropenem 1 g IV every 8 hrs or Imipenem 500 mg IV every 6 hrs or Zosyn [Piperacillin-tazobactam] 4.5 g IV every 6-8 hrs. Add Vancomycin in patients with sepsis, hypotension, mental status changes or focal infection like pneumonia or cellulitis or central line infections. Include anaerobic coverage if anaerobic infection is suspected or found.

If patient has a history of an immediate-type hypersensitivity reaction like hives or bronchospasm, they can not be given beta-lactams or carbapenems. Give Aztreonam plus Vancomycin or Ciprofloxacin plus Clindamycin.

IV fluids-30ml/kg body weight if in sepsis. Consult Critical Care physician if BP does not improve even after 3 liters of iv fluids.

Repeat Lactic acid level in 3hrs if sepsis alert activated.

Request ID evaluation as they help guide care further during the hospital stay until discharge. Some restricted broad spectrum antibiotics can only be ordered by ID specialist per hospital bylaws.

Follow blood cultures, Urine culture. If blood cultures are positive, they have to be repeated daily or every two days until they are negative.

Consider further imaging if routine tests are negative for any source of infections.

Monitor Platelet count, Hb and Hematocrit to transfuse if needed.

Consider Hematology/Oncology evaluation

If there is a suspicion for CDiff colitis, make sure to order stool for CDiff toxin as soon as possible so it will be considered as POA [Present on admission] and hospital won’t be dinged later for quality measure.

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