FEBRILE NEUTROPENIA

DESCRIPTION

Febrile neutropenia is defined as an absolute neutrophil count of < 0.5 x109/L with a temperature of greater than 38°C for > 1 hour. This is a medical emergency as these patients can rapidly develop features of severe sepsis (multi-organ failure and/or hypotension).

GENERAL MEASURES

Treat the underlying cause of neutropenia, if applicable. Withdraw any drug that may cause neutropenia.

Take blood cultures before starting antimicrobial therapy. Once culture results are available, adjust treatment to the most appropriate narrow spectrum agent.

MEDICINE TREATMENT

For patients with febrile neutropenia within 48 hours of admission:

3rd generation cephalosporin, e.g.:

• Ceftriaxone, IV, 1 g daily.

PLUS

• Gentamicin, IV, 6 mg/kg daily.

If IV line infection is suspected as the cause at any stage:

ADD:

• Vancomycin, IV, 20 mg/kg/dose 12 hourly.

o Monitor trough levels after the third dose.

o Adjust dose to maintain a trough level of 15–20 micromol/L.

If fever develops after 48 hours of admission:

Choice will depend on local susceptibility patterns. One or more of the

following antibiotics/classes must be available:

• Piperacillin/tazobactam, IV, 4.5 g 8 hourly or cefepime, IV, 1 g 12

hourly.

OR

Carbapenem with activity against Pseudomonas, e.g.:

• Meropenem, IV, 1 g 8 hourly or Imipenem, IV, 500 mg 6 hourly.

Note:

Ertapenem is not recommended because it is not effective for pseudomonas

species which are important pathogens in this setting.

If no response after 5–7 days:

ADD

• Amphotericin B, IV, 1 mg/kg daily in dextrose 5 % over 4 hours.

o Ensure adequate hydration to minimise nephrotoxicity.

o Regular, e.g. 3 times a week, monitoring of potassium, magnesium

and renal function is essential.

Duration of therapy:

If neutrophil count increases to > 0.5 109/L, continue for 2 days after fever has settled.

If neutrophil count remains 0.5 109/L, continue for 7 days after fever has settled.

REFERRAL/CONSULTATION

» All cases – consult with haematologist/oncologist.

Reference and further reading

Standard Treatment Guidelines and Essential Medicines List for South Africa 2012 Edition