Febrile Neutropaenia

Febrile neutropaenia is the combination of both:

Fever
- Single temperature ⩾38.5°C
- Sustained temperature ⩾38.0°C for >1 hour
Neutropaenia
- Current count <0.5×10⁹/L
- Current count <1×10⁹/L, with predicted nadir <0.5×10⁹/L over next 48 hours

Epidemiology and Risk Factors

Risk factors are all some form of immunosuppression, namely:

Chemotherapy
Organ transplant
Clozapine-induced agranulocytosis
Chronic granulomatous disease

Pathophysiology

Aetiology

Clinical Features

Diagnosis should be suspected in any haematology or oncology patient who has:

Neutropaenic sepsis may occur without fever or other infective features, and has a high mortality.

Received chemotherapy in the previous 14 days
Is neutropaenic

Assessment

History:

Exam:

Investigations

Bedside:

TTE
- Endocarditis

Laboratory:

Blood
- Cultures
  - Peripheral
  - Every indwelling line
  - Strictly prior to antibiotics
- FBE
- UEC
- LFT
Faeces
- Culture
- Viral studies
- C. difficile toxin

Imaging:

CXR
CT
- Brain
- Chest
- Consider pan-scan

Other:

LP
- Gram stain and culture

Diagnostic Approach and DDx

Management

Goals of management

Resuscitation:

Specific therapy:

Pharmacological
- Aggressive antimicrobial therapy
  - Broad-spectrum anti-pseudomonal:
    - Tazocin 4.5g IV Q8H
    - Cefepime 2g IV Q8H
    - Ceftazedime 2g IV Q8H
  - With alterations or additions if:
    - Known or likely ESBL
      - Change to Meropenem 2g IV Q8H.
    - Known or likely MRSA
      - Add vancomycin
    - CLABSI
      - Add vancomycin
    - Severe sepsis/septic shock
      - Add gentamycin 4-7mg/kg
      - Add vancomycin
    - Suspected PJP
      - Add trimethoprim/sulfamethoxazole
    - Suspected HSV/CMV
      - Add acyclovir or ganciclovir
    - Fever persists at 48 hours
      - Add vancomycin
    - Fever persists at 96 hours
      - Add antifungal
        
        Caspofungin
        For fluconazole-resistant candida.
        
        Voriconazole
        If suspected pulmonary infection (poor caspofungin penetrance).
        
        Amphotericin
        If concern for mucor, cryptococcus, or zygomycetes.
- G-CSF
  - Stimulates neutrophil production, and release of immature neutrophils
    ↑ WCC, with a lesser degree of immunorecovery.
  - Associated with↓ infection severity
  - Continue until neutrophil count >1×10⁹/L
Procedural
Physical

Supportive care:

Disposition:

Preventative:

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

Prognosis

Poor prognosis associated with:

Number and extent of organ failures
Multi-organ failure has close to 100% ICU mortality.
Allogenic transplant
Intubation
↑ VAP risk.
Renal disease requiring haemodialysis