Day #266 - Febrile Neutropenia

Today we discussed a case of a patient with multiple immunological deficiencies (a review of primary immunodeficiencies is available here)

Multiple myeloma with dysgammaglobulinemia predisposing to infections with encapsulated organisms like streptococcus pneumoniae and other bacterial infections like staphylococci.

High dose prednisone leading to relative deficiencies with cell mediated immunity predisposing to intracellular organisms (i.e. salmonella, listeria), mycobacterial, and fungal infections.

TNF alpha antagonist leading to further risk of fungal and mycobacterial infections

And drug induced febrile neutropenia predisposing to infection with bacteria including pseudomonas as well as fungi such as candida species, aspergillus, and other moulds.

The 2002 (under revision) IDSA guidelines for the management of febrile neutropenia are available here.

When initially seeing the febrile neutropenic patient, the goals (in general) are to:

1. Stablize and rescucitate as appropriate
2. Identify any specific focus of infection on history and physical exam
   
   • Pay attention in particular to sinuses and dental sources, mucositis, new murmurs, skin foci including central line sites and tunnels, evidence of pneumonia, evidence of intrabdominal focus, peri-rectal exam (no DRE)
   • CXR for all cases. Sinus, CT thorax, abdominal, other imaging as clinically indicated.
     
3. Obtain cultures from all sites including two sets of blood cultures and cultures from any indwelling intravenous lines.
   
4. Initiate broad spectrum antibiotic therapy to cover for usual pathogens implicated in febrile neutropenia adjusting/broadening to include identifiable focus
   
   • In general an antipseudomonal beta-lactam combined with an aminoglycoside is a standard regimen with the addition of VANCOMYCIN in patients with indwelling intravenous catheters, risk for MRSA, or who come in pre-treated with quinolone prophylaxis
5. Tailor antibiotics to culture results but remain broad-spectrum while neutropenic
   
   • i.e. if no gram positive identified can consider stopping VANCOMYCIN at 72h
     
   • if no pseudomonas or gram negative identified at 72h can consider stopping aminoglycoside and continuing the beta-lactam