Spectrum: Local Antimicrobial Stewardship, for Eastern Health

FN - General

Note

Febrile neutropenia (FN) is an emergency.

All patients should have STAT blood culture and antimicrobials (door-to-needle) within 60min of presentation

Neutropenics have attenuated signs/symptoms of infection (lack of inflammatory response), so minor focal symptoms should be regarded carefully

Most FN is caused by the patient’s own flora.

Approx. 1/5 will have a definable focus of infection (i.e. pneumonia, cellulitis), and a similar fraction will be bacteremic.

Case definition

A fever of 38.3ºC once or >38ºC for one hour in a patient with an absolute neutrophil count of <500/µL, or anticipated ANC<500/µL in the next 48hrs.

ANC<100/µL is considered profound neutropenia

A thorough search for a definable infection should be made

Pertinent history

Detailed review of systems for infectious/localizing symptoms, previous history of colonization or infection by a drug-resistant organism, antimicrobial treatment in the last 6mo, timing of last chemotherapy, infectious contacts, travel, and comorbidities

Physical examination

Meticulous examination of skin and mucous membranes for rash, cutaneous lesions, stomatitis/pharyngitis/mucosal lesions, odontogenic infection, along with perianal inspection (AVOID DRE). Inspect intravenous catheter sites. Detailed full exam includes volume status, lymph nodes, neurologic, cardiorespiratory, genitourinary and careful abdominal exam.

Investigations

  • Blood Cx (should include all CVCs + 1 peripheral site)

  • Urine Cx

  • CXR

  • CBC

  • Electrolytes

  • INR/PTT

  • Renal and hepatic panel.

Risk Stratification