May 16, 2018
ASCO and IDSA Practice Guideline Update on Outpatient Management of Febrile Neutropenia in Adults with Cancer: An expert panel of the American Society of Clinical Oncology (ASCO) and the Infectious Diseases Society of America (IDSA) conducted a systematic review and provided updated recommendations for outpatient evaluation and treatment of fever and neutropenia in adults treated for malignancy. The guideline was developed to assist healthcare providers in identifying appropriate patient candidates for outpatient management of fever and neutropenia based on clinical criteria and validated scoring systems. Clinicians must inform patients about safety practices and patient/caregiver responsibilities after discharge because they have important roles in ensuring the safe and effective outpatient management of febrile neutropenia.
An immunocompromised host is a patient with defects in host defenses that predispose to infection. Risk factors include neutropenia, immune system defects (from disease or immunosuppressive drug therapy), compromise of natural host defenses, environmental contamination, and changes in normal flora of the host.
Immunocompromised patients are at high risk for a variety of bacterial, fungal, viral, and protozoal infections. Bacterial infections caused by gram-positive cocci (staphylococci and streptococci) occur most frequently, followed by gram-negative bacterial infections caused by Enterobacteriaceae and Pseudomonas aeruginosa. Fungal infections caused by Candida and Aspergillus, as well as certain viral infections (herpes simplex virus [HSV], cytomegalovirus [CMV]), are also important causes of morbidity and mortality.
Risk of infection in neutropenic patients is associated with both the severity and duration of neutropenia. Patients with severe neutropenia (absolute neutrophil count less than 500 cells/mm3 [less than 0.5 × 109/L]) for greater than 7 to 10 days are considered to be at high risk of infection.
Fever (single oral temperature of greater than or equal to 38.3°C [greater than or equal to 101°F], or a temperature of greater than or equal to 38°C [greater than or equal to 100.4°F] for greater than or equal to 1 hour) is the most important clinical finding in neutropenic patients and is usually the stimulus for further diagnostic workup and initiation of antimicrobial treatment. Infection should be considered as the cause of fever until proven otherwise. Usual signs and symptoms of infection may be altered or absent in neutropenic patients. Appropriate empiric broad-spectrum antimicrobial therapy must be rapidly instituted to prevent excessive morbidity and mortality.
Empiric antimicrobial regimens for neutropenic infections should take into account patients’ individual risk factors, as well as institutional infection and susceptibility patterns. The significant morbidity and mortality associated with gram-negative infections require that initial empiric regimens for treatment of febrile neutropenia have good activity against P. aeruginosa and Enterobacteriaceae. Parenteral regimens most commonly recommended for initial inpatient treatment include monotherapy with an antipseudomonal β-lactam, or a combination regimen consisting of an antipseudomonal β-lactam, plus an aminoglycoside. Low-risk patients may be successfully treated with oral antibiotics (ciprofloxacin plus amoxicillin-clavulanate), with the treatment setting determined by the patient’s clinical status.