Abstract. This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that. Risk of febrile neutropenia (FN) should be systematically assessed (in consultation with infectious disease specialists as needed), including. Febrile neutropenia (FN) is a serious complication of cancer chemotherapy that The Infectious Diseases Society of America (IDSA), National.

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Accordingly, many experts do not recommend fluoroquinolone prophylaxis for neutropenic autologous HSCT recipients. If fever persists after empirical antibiotics have been started, fegrile 2 sets of blood cultures via catheter or periphery may be obtained on each of the next 2 days.

Fever and Neutropenia in Adults with Cancer

However, there are specific circumstances that warrant the addition of vancomycin or another antibiotic with enhanced gram-positive coverage to the initial empirical regimen for fever and neutropenia Table 4. A recent survey found that practicing oncologists frequently employ levofloxacin monotherapy to treat low-risk patients with fever and neutropenia.

All effective empirical antibiotic regimens combination or monotherapy share certain essential features, including bactericidal activity in the absence of white blood cells, anti-pseudomonal activity, and minimal toxicity. After initial defervescence neutfopenia with empirical antibiotics, any recrudescent fever should be evaluated with cultures as a new episode of possible infection.

IDSA GUIDELINES Bundle (free trial)

Fluconazole is an effective prophylactic antifungal in allogeneic HSCT recipients when used from the onset debrile conditioning, through neutropenia, and extended to at least day 75 after receipt of transplant.

Its bioavailability is variable and unreliable if not taken in conjunction with food [ — ]. Ciprofloxacin should not be employed as a solo agent because of its poor coverage of gram-positive organisms [ 1221, — ].

A recent comparative open trial of voriconazole and itraconazole among allogeneic HSCT recipients demonstrated fewer interruptions of study drug and a trend to fewer fungal infections among those who received voriconazole but comparable survival at and days.

Patients with FN at high risk of serious complications are treated with intravenous empiric antibiotic therapy in the inpatient setting. Identification of a clinically or microbiologically documented infection should guide any changes to the initial empirical antibiotic regimen. A 2-fold or greater increase in the attack rate of aspergillosis during any 6-month period should prompt an examination of the environment, observation of staff for breaks in infection control technique and procedures, and inspection of the ventilation system.


Nasal wash or BAL specimens are recommended to evaluate for symptoms of respiratory virus infection, particularly during an outbreak or during winter. A randomized trial comparing cefoperazone plus piperacillin, ceftazidime plus piperacillin, and imipenem alone.

Selected hospitalized patients who meet criteria for being at low risk may be transitioned to the outpatient setting to receive either IV or oral antibiotics, as long as adequate daily follow-up is neutrolenia B-III.

Guidelines in the Management of Febrile Neutropenia for Clinical Practice

Another important unresolved question is use of the preemptive antifungal approach in patients who are already receiving anti-mold prophylaxis [ ]. Bloodstream infections due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae: Diarrhea should be assessed by analyzing a stool sample for C. VRE colonization is an important risk factor for subsequent invasive disease [ 15 ]. Other oral regimens, including levofloxacin or ciprofloxacin monotherapy, or ciprofloxacin plus clindamycin, are less well studied but are commonly used B-III.

The FDA study, which included both trial data and patient-level data controlled for mortality-related risk factors, found no statistically significant increase in day mortality associated with cefepime use RR, 1.

These agents should be considered for specific clinical indications, including suspected catheter-related infection, skin and soft-tissue infection, pneumonia, or hemodynamic instability. More recently, Cordonnier neutgopenia al [ ] demonstrated, in a randomized trial, that preemptive antifungal therapy was a safe alternative to empirical antifungal therapy in a selected group of high-risk neutropenic patients.

The duration of systemic antimicrobial therapy depends on several factors, including whether the catheter was removed or retained, neutropennia to antimicrobial therapy within 48—72 h resolution of fever and bacteremiaand whether complicated infection deep tissue infection, septic thrombosis, or endocarditis [ ] is present. Prophylaxis stop-dates for patients with acute leukemia generally coincide with myeloid reconstitution. If necessary, the entire Panel will reconvene to discuss potential changes.

For patients receiving fluconazole prophylaxis, fluconazole-resistant Candida infections, such as those due to Candida krusei or Candida glabrataor an invasive mold infection are more likely because the drug lacks anti-mold activity.

Empirical antibiotics against gram-positive infections for febrile neutropenia: Patients with respiratory signs and symptoms should have a chest radiograph to rule out pneumonia.

Serious infections due to S. Although voriconazole failed to meet the strict statistical measurement of noninferiority when compared with liposomal amphotericin B [ ], most clinicians regard it as a reliable alternative [ — ]. Because staphylococci and microaerophilic viridans group streptococci are encountered among fluoroquinolone prophylaxis recipients, some authorities have advocated adding a gram-positive agent to the prophylactic regimen [ ].


However, as with other hospitalized patients, when contact with body fluids is anticipated, standard barrier precautions should be followed [ ]. High use of fluoroquinolones in oncology patients has been linked to increases in infections due to fluoroquinolone-resistant E. Large surveys of fluoroquinolone use in children who do not have cancer have not identified serious problems, although the drugs may be associated with more musculoskeletal adverse effects, compared with other classes of antibiotics [ — ].

All persons, including HCWs, must sanitize their hands before entering and after leaving the rooms of neutropenic and all other patients. Early in the development of cytotoxic chemotherapy, during the s and s, gram-negative pathogens predominated.

An IV-to-oral switch in antibiotic regimen may be made if patients are clinically stable and gastrointestinal absorption is felt to be adequate A-I. In low-risk patients without documented infection, continuing antibiotic therapy until resolution of both fever and neutropenia is the standard approach. Co-administration of mold-active triazole-based prophylaxis with vinca alkaloids or high doses of cyclophosphamide and anthracyclines should be avoided until these interactions have been better studied.

An outpatient treatment course with oral or IV antibiotics may be considered after a brief inpatient stay, during which IV therapy is initiated, fulminant infection is excluded, the patient is deemed to be clinically stable and at low-risk for complications, assessment of family support is completed, and the status of initial culture specimens may be ascertained [ 424566 ].

Diagnostic endoscopy rarely causes bacteremia [ ] but generally should be avoided in neutropenic thrombocytopenic patients because of the risk of bleeding and perforation [ ]. Antifungal therapy should be instituted if any of these indicators of possible invasive fungal infection are identified. Recognition of these resistant species requires careful interpretation of hospital and organism-specific antibiograms.

Initial management of fever and neutropenia. Other herpesvirus infections occur in the post-HSCT setting, including infections due to cytomegalovirus and human herpesvirus – 6.