Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Triage and obtain cultures; start antipseudomonal β‑lactam within 60 minutes.
- Risk‑stratify (MASCC/CISNE); choose inpatient IV vs outpatient oral regimen.
- Add MRSA coverage only when specific indications present; consider antifungals if persistent fever after 4–7 days and neutropenia continues.
- Daily reassessment; de‑escalate based on cultures and clinical response; plan growth factor per oncology.
Clinical Synopsis & Reasoning
Fever with ANC <500 (or expected to decline) after chemotherapy. Obtain cultures quickly and start an antipseudomonal β‑lactam within 60 minutes; add MRSA coverage only with specific indications. Use MASCC/CISNE for risk and consider outpatient oral therapy for low‑risk patients.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Blood cultures (peripheral + line) before antibiotics | Source ID | High yield | Do not delay antibiotics |
| CXR/CT and urinalysis | Source search | Pneumonia/UTI common | Tailor imaging to symptoms |
| Risk scores (MASCC, CISNE) | Disposition | Low vs high risk | Guides IV vs oral/outpatient |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Cefepime or Piperacillin‑tazobactam or Meropenem | Antipseudomonal β‑lactam | Minutes | First‑line monotherapy | Add vanc only if indicated |
| Vancomycin (indications only) | Glycopeptide | Minutes | Catheter infection, SSTI, pneumonia, hemodynamic instability, MRSA colonization | Avoid routine use |
| Levofloxacin + Amoxicillin/clavulanate (low‑risk oral) | Oral step‑down | Hours | For stable low‑risk | Adjust by allergies/local resistance |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ASCO/IDSA guideline update on febrile neutropenia — Link