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  • image An immunocompromised host is a patient with defects in host immune 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.

  • image 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.

  • image 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 [0.5 × 109/L]) for greater than 7 to 10 days are considered to be at high risk of infection.

  • image Fever (single oral temperature of greater than or equal to 38.3°C [100.9°F], or a temperature of greater than or equal to 38°C [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.

  • image 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 (fluoroquinolone plus amoxicillin-clavulanate), with the treatment setting determined by the patient’s clinical status.

  • image Neutropenic patients who remain febrile after 3 to 5 days of initial antimicrobial therapy should be reevaluated to determine whether treatment modifications are necessary. Common regimen modifications include addition of vancomycin (if not already administered) and antifungal therapy (amphotericin B, an echinocandin, or fluconazole). Therapy should be directed at causative organisms, if identified, but broad-spectrum regimens should be maintained during neutropenia.

  • image The optimal duration of therapy for febrile neutropenia is controversial. The decision to discontinue antimicrobials is based on resolution of neutropenia, defervescence, culture results, and clinical stability of the patient.

  • image Prophylactic antimicrobials are administered to cancer patients expected to experience prolonged neutropenia, as well as to hematopoietic stem cell and solid-organ transplant recipients. Prophylactic regimens may include antibacterial, antifungal, antiviral, or antiprotozoal agents, or a combination of these, selected according to risk of infection ...

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