Î After fever has been documented in a neutropenic patient and pre-
treatment blood samples have been drawn, administer the first dose of
empiric therapy within 1 hr after triage from initial presentation in the
clinic, emergency room, or hospital department.
Î Patients with cancer and FN at low risk for medical complications as
defined herein may be given oral empiric therapy with a fluoroquinolone
(ciprofloxacin or levofloxacin) plus amoxicillin/clavulanate (or plus
clindamycin for those with penicillin allergy).
Note: A fluoroquinolone is NOT recommended for initial empiric therapy of neutropenic
cancer patients who develop fever after receiving fluoroquinolone-based antibacterial
prophylaxis, or in environments where the prevalence of fluoroquinolone resistance is
>20%. For these patients, and if deemed appropriate by the treating physician, IV therapy
is recommended with a regimen suitable for outpatient administration, provided they meet
clinical and other criteria for outpatient management.
Î Hospitalized stable and responding low-risk patients receiving initial
empiric IV antibacterial therapy, particularly those classified as having
unexplained FN, may be considered for stepdown to an orally administered
regimen and early discharge for outpatient follow-up and monitoring.
Î Observe patients identified as low risk and selected for outpatient
management for ≥4 hr before discharge to verify they are stable and can
tolerate the regimen they will receive.
Î Hospitalize patients with FN from cancer therapy who are at high risk for
medical complications and use IV antimicrobial therapy. (See also IDSA
recommendations [2010] http://cid.oxfordjournals.org/content/52/4/e56.
full)
Outpatient Management
Î Evaluate frequently for ≥3 days in clinic or at home.
Î Contact by telephone daily or frequently to verify (by home thermometry)
that fever resolves.
Î Monitor ANC and platelet count for myeloid reconstitution.
Î Schedule frequent return visits to clinic.
Î Evaluate for admission to the hospital if any of the following occurs:
• Persistent neutropenic fever syndrome develops
• Fever recurs
• New signs or symptoms of infection appear
• Use of oral medications is no longer possible or tolerable
• A change in the empiric regimen or an additional antimicrobial drug becomes necessary
• Microbiologic tests identify species not susceptible to initial regimen.
ÎRe-evaluate low-risk patients who fail to defervesce after 2-3 days of an
initial empiric broad-spectrum antibiotic regimen to detect and treat a new or
progressing anatomical site of infection and to consider for hospitalization.
Treatment
