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Fever and Neutropenia

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Diagnosis and Assessment Risk Assessment ÎRisk stratification is a recommended starting point for managing patients with fever and neutropenia. ÎAssessment of risk for complications of severe infection should be undertaken at presentation of fever (A-II). Risk assessment may determine type of empirical antibiotic therapy (oral vs. intravenous [IV]), venue of treatment (inpatient vs. outpatient), and duration of antibiotic therapy (A-II). Î — those with anticipated prolonged (> 7 days) and profound neutropenia (ANC ≤ 100 cells/mm3 following cytotoxic chemotherapy) and/or significant medical co-morbid conditions, including hypotension, pneumonia, new onset abdominal pain or neurologic changes. Such patients should be in hospital for empirical therapy (A-II). Î — those with anticipated brief (≤ 7 days) neutropenic periods and no or few co-morbidities — are candidates for oral empirical therapy (A-II). ÎFormal risk classification may be performed using the validated Multinational Association for Supportive Care in Cancer (MASCC) scoring system (B-I). Table 1. The MASCC Risk-Index Score Characteristic Burden of febrile neutropenia with no or mild symptomsa No hypotension (systolic blood pressure > 90 mmHg) No chronic obstructive pulmonary diseaseb Solid tumor or hematologic malignancy with no previous fungal infectionc No dehydration requiring parenteral fluids Burden of febrile neutropenia with moderate symptomsa Outpatient status Age < 60 years NOTE: The maximum value of the score is 26. Scores below 21 are high risk (B-I). a and 5 are not cumulative. b Weight 5 5 4 4 3 3 3 2 Burden of febrile neutropenia: Refers to the general clinical status of the patient as influenced by the febrile neutropenic episode. It should be evaluated on the following scale: no or mild symptoms (score of 5); moderate symptoms (score of 3); severe symptoms or moribund (score of 0). Scores of 3 Chronic obstructive pulmonary disease (active chronic bronchitis or emphysema) requiring a treatment at the presentation of the febrile neutropenic episode: decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or bronchodilators. c Previous fungal infection: Demonstrated fungal infection or empirically treated suspected fungal infection. 1 Hi g h - r i s k p a t i e n t s L o w - r i sk p a t i e n t s

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