Antifungal agents can be withheld in a specific subset of high-risk febrile neutropenic patients. These patients include those who remain febrile after 4-7 days of broad-spectrum antibiotics but are clinically stable and without clinical or radiographic signs of fungal infection.
Fever is “a temperature > 38.5 on any occasion or > 38.0 for > 1 hour”.
Neutropenia is “a Neutrophil count of < 1.0 x /I”.
Fever is always presumed to be ineffective until proven otherwise.
Often very few clinical findings.
If left untreated there is a very high mortality.
Take a careful history especially with regards to the typr of cancer & its management.
Ensure temperature, pulse, resp rate, BP & oxygen saturations are documented.
Thorour examination including oral cavity, perianal, skin & venous access sites.
Early recognition of septic shock is essential to patient survival.
High risk patients are patients with cancer plus at least one of:
· Haemotological malignancy,
· Myelosupressive chemotherapy,
· Concurrent chemotherapy or radiotherapy,
· Age >60,
· Co-morbidities eg Daibetes,
· Bone marrow involvement of cancer,
· Significant mucusitis,
· On steroid doses of > 25 mg Prednisolone,
· Rapidly declining Neutrophil count,
Recent hospitalization for infection.
1. Discuss with medical officer & Oncologist expediently (preferably) prior to
2. Reverse barrier nurse,
3. ABC’s & Resuscitation as indicated,
4. All patients should get FBC, Blood Cultures (including one from each lumen of any IV
catheter plus a peripheral sample- don’t flush tubes first), U&E’s, LFT’s, urinalysis & MSU,
CXR & other tests as indicated (Sputum, feaces, LP etc),
5. Urgent treatment with IV antibiotics within ½ hour of arrival.
6. HIGH RISK patients IV Caeftazidime 2 g tds (or Ciprofloxacin 400 mg IV BD if
hypersensitive to Penicillin or Cephalosporins.) plus IV Gentamicin 5mg/kg,
7. Low risk patients IV Ceftazidime 2 g tds,
8. If suspected IV catheter infection add IV Vancomycin 1g BD (modify dose in renal
9. For suspected bowel related or perianal focus add IV Metronidazole 500mg BD,
10. If severe beta-lactam allergy replace Cefepime with IV Ciprofloxacin 400 mg BD,
11. If clinical Oropharyngeal candidiasis or high dose steroids add Fluconazole 400 mg IV
or orally daily,
12. Choice of antibiotic should be modified on basis of culture results,
13. Consider use of G-CSF to increase neutrophil count,
14. If fever unresolved after 48 hours & negative cultures consider CT chest & adding IV
15. If fever persists a further 48 hours consider adding Fluconazole.