Key Points
Î Only use antibacterial and antifungal prophylaxis if neutrophils are
expected to remain <100/µL for >7 days, unless other factors (see full text
guidelines) increase risks for complications or mortality.
Î An oral fluoroquinolone is preferred for antibacterial prophylaxis and an
oral triazole for antifungal prophylaxis.
Î Interventions such as footwear exchange, protected environments,
respiratory or surgical masks, a "neutropenic" diet, or nutritional
supplements are NOT recommended because evidence is lacking of clinical
benefits to patients from their use.
Î Assess risk for medical complications in patients with fever and
neutropenia using Talcott's rules or the Multinational Association for
Supportive Care in Cancer (MASCC) score (see Tables 2 & 3). Talcott's
Group 4 or MASCC score ≥21 with no other risk factors (see Table 4) define
low risk.
Î An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin
for those with penicillin allergy) is recommended for initial empiric therapy,
unless fluoroquinolone prophylaxis was used before fever developed (see
full text guidelines for alternatives).
Note: Lacking sufficient data from controlled trials on outpatients, these recommendations
are based primarily on results from trials on inpatients and the expert opinion of the panel
members.
Î Risk for an FNE in afebrile patients with neutropenia should be
systematically assessed (in consultation with infectious disease specialists
as needed) for patient-related, cancer-related, and treatment-related
factors (see Table 1).
Î Fever in a patient with neutropenia from cancer therapy should be assumed
to be due to a bacterial infection if an alternative explanation is lacking.
Î The initial diagnostic approach should maximize the chances of establishing
a clinical and microbiologic diagnosis that may affect antibacterial choice
and prognosis.
Assessment