Neutropenia & Neutropenic Fever¶
Jennifer Marvin-Peek
Background¶
- Neutropenia: absolute neutrophil count (ANC) < 1500
- Severe neutropenia: absolute neutrophil count (ANC) <500 (Use manual count if available)
Mechanism | Causes | Example (s) |
---|---|---|
Neutrophil production | Drug associated | Cytotoxic or immunosuppressive agents Methimazole, PTU, Colchicine Macrolides, Bactrim, Dapsone, Vancomycin Amphotericin, Acyclovir, Ganciclovir TCAs, Clozapine, Carbamazepine, Valproate ACEI, Digoxin, Propranolol, Procainamide |
Radiation exposure | ||
Malignancies | Leukemias, MDS | |
Infection | Hepatitis, HIV, EBV, CMV Rickettsia, Tularemia, Typhoid, TB |
|
Nutritional deficiency | Vitamin B12, Folate, Copper | |
Other | Aplastic anemia, Benign ethnic neutropenia | |
Redistribution | Splenomegaly | Margination and sequestration |
Congenital | Genetics | Benign ethnic neutropenia, familial neutropenia |
Immune destruction | Autoimmune disorders | RA, SLE |
Other | Autoimmune neutropenia |
Management¶
- If ANC <500
- Check all lines/IVs for erythema and induration daily
- Check mouth for mucositis, mouth care after meals and before bed
- Assess for Neutropenic Fever & Complications – see below
- Evaluate for indications for prophylaxis – see below
- No evidence to support use of neutropenic diet
- No digital rectal exams or enemas/suppositories (risk of bacterial translocation)
Neutropenic Fever¶
- ANC <500 and T >100.4 °F or 38.0 °C
- Neutropenic pts are unable to mount an adequate immune response and can become critically ill very quickly
- Do not wait for a temp re-check, you need to start antibiotics immediately
Evaluation¶
- Chest X-ray
- Two sets of blood cultures (one from PICC/port if present)
- Urinalysis AND urine culture (not the reflex order set)
- If diarrhea, get C. diff PCR
- If abdominal pain, get CT A/P with IV contrast
Management¶
- Empirically treat with Cefepime
- Indications for Vancomycin:
- Hemodynamically unstable
- Severe mucositis
- Focal consolidation on CXR
- Erythema/induration around line
- Concern for skin/soft tissue infection
- GPCs in blood
- Fever continues >24h on cefepime
- Additional Coverage:
- If abdominal pain/diarrhea: Flagyl 500mg q8h
- Concern for C-diff: PO Vancomycin 125mg q6h
- Still fevering on Cefepime at 72 hrs (differs by attending) Meropenem
- Fungal coverage: Consider if risk factors (TPN) or persistent fevers
(>72hrs)
- Micafungin 100 mg IV daily or Voriconazole 200mg PO BID
Neutropenic Complications¶
-
Mucositis
- Presentation
- Can range from mouth soreness to severe erosions preventing eating/drinking
- Can become secondarily infected with Candida, HSV
- Management
- Routine oral care with a soft toothbrush to remove plaque
- Oral rinses with saline and/or sodium bicarbonate
- Magic mouthwash for symptomatic relief (or viscous lidocaine at the VA)
- Typically recovers quickly when ANC > 500
- Presentation
-
Neutropenic enterocolitis (Typhlitis)
- Life-threatening bacterial translocation due to breakdown of gut-mucosal barrier
- Presentation
- Abdominal pain + fever
- ± abdominal distension, nausea, vomiting, watery and/or bloody diarrhea
- Diagnosis
- CT A/P with contrast, consider C. diff PCR if diarrhea
- Treatment
- Cefepime/Flagyl OR Zosyn
- If no perforation/abscess on CT scan, typically continue until 14 days after ANC recovers >500 and abdominal pain resolves
- Can change to cipro/flagyl once ANC >500
- If perforation/abscess: will need imaging to confirm resolution, and longer duration of abx
-
Neutropenic Prophylaxis
- Used if ANC is expected to be \< 500 for > 7 days
Most Common Regimens | Alternatives | |
---|---|---|
Bacterial | Levofloxacin 500mg daily (renally dosed) | Cefdinir 300mg BID |
Viral | Valacyclovir 500mg BID | Acyclovir 400mg BID (renally dosed) |
Fungal | Fluconazole 400mg daily | Posaconazole 300mg BID x2 days 300mg daily (AML induction for aspergillus) Micafungin 50mg IV daily |
PJP (if steroids) | Inhaled pentamidine 300mg qmonthly | Dapsone (check G6PD) Avoid Bactrim (risk of myelosuppression) |
Filgrastim (G-CSF – Neupogen/Zarxio/Granix)¶
- Induces bone marrow production of neutrophils
- Dose: either 300mcg or 480mcg (rounded from 5 mcg/kg/day)
- Common side effects: fatigue, nausea
- PEG-filgrastim (Neulasta): long-acting version that is only given as an outpatient
Last update:
2022-06-24 23:35:57