Best practice explained
Delay in treatment leads to a poorer outcome. Antibiotics must be given as soon as possible after the blood cultures are drawn.
The choice of antibiotics to be used is reviewed by the oncology department every few years and is based upon the local resistance patterns from blood cultures in oncology patients.
The protocol summary is a practical way to approach patients with FN.
A standardised approach starts with a clear and accepted definition of fever and neutropenia. We have defined:
- Fever as an oral temperature of 38.3 c, or 38.0 c twice at least 1 hour apart.
- Neutropaenia is defined as an absolute neutrophil count (ANC) of less than 1000 cells/μL.
Definitions of high and low risk patients given in Risk categories.
The use of DFA on NPW samples can also help the clinician to determine if the episode has a viral aetiology.
It is possible to manage these low risk patients with daily re-evaluation and ceftriaxone IV every 24 hours (or oral ciprofloxacin) until blood cultures are negative at 48-72 hours.
Moderate/High risk patients:
In moderate and high risk patients, one approach is to admit to the hospital for therapy with a broad spectrum agent such as piperacillin-tazobactam or meropenem.
The addition of an aminoglycoside to the empiric regimen is still commonplace in paediatric practice, but as we discussed earlier, there is now little evidence to support its use. If an aminoglycoside is used, the choice of agent depends on the local microbiological data. In institutions where Enterococcus spp. is a predominant pathogen, gentamicin is considered a better agent owing to its synergistic properties when given along with β-lactams. If Pseudomonas aeruginosa infections are predominant, then tobramycin may be a better choice.
In patients presenting with septic shock, especially in patients with AML (at risk for VGS sepsis), or in patients with suspected MRSA sepsis (e.g.: previously colonised or with tunnel infection), the empiric addition of vancomycin is recommended.
Persistant febrile neutropenia:
Patients with ongoing FN for more than 3-5 days should be assessed for possible invasive fungal disease.
In high risk patients, fungal blood culture should be drawn and a HRCT of the chest (+/- sinuses) should be performed prior to the start of antifungal therapy with either amphotericin B, a wide spectrum triazole (ie: voriconazole) or an echinocandin (caspofungin).
Finally, it is important to remind the clinician of the necessity, upon identification of an etiological pathogen, to review and, if possible, narrow the spectrum of the antibiotic therapy.