CURRENT Essentials of Critical Care.pdf

Chapter 10 Infectious Disease 147■■■Neutropenic FeverEssentials of Diagnosis• Single temperature 38.3°C, or 38°C for 1 hour, in patientwith neutropenia (absolute neutrophil count 500/L, or1000/L with anticipated decline to 500/L)• Up to 90% of neutropenic patients develop fever• Duration, depth, cause of neutropenia determine likelihood ofinfection; infection most common cause of death during neutropenicepisodes• Common pathogens include aerobic gram-negative bacilli, withincreasing incidence of gram-positive cocci; but etiology identifiedin only 30–50%; only 10–20% have documented bacteremiaor fungemia• Fever often only sign of infection; however, complete historyand careful examination essential (inspect skin, mucous membranes,perirectal area)Differential Diagnosis• Drug fever or allergic reaction• Fever secondary to hematologic malignancy• Deep venous thrombosisTreatment• Prompt initiation of empiric antimicrobial therapy using antipseudomonalbeta-lactam antibiotic with or without aminoglycoside• Add antistaphylococcal/streptococcal agent (vancomycin) in patientsat higher risk for gram-positive cocci (central IV catheter,mucositis, prior treatment with fluoroquinolones)• Antifungal agents indicated in prolonged neutropenic fever (5days) despite broad-spectrum antibacterial drugs• Avoid rectal exams, which can lead to bacteremia■ PearlPhysical exam may be misleading because lack of neutrophils precludesusual pus formation, fluctuance, or development of abscesses.ReferenceHughes WT: 2002 guidelines for the use of antimicrobial agents in neutropenicpatients with cancer. Clin Infect Dis 2002;34:730. [PMID: 11850858]