Breast Care Center

Protocol for Management of Neutropenic Fever


Definitions

Fever: oral temp of  ≥38.3 C (101F) – single spike
    Or
    ≥ 38.0 (100.4F) for at least one hour
     
Neutropenia:  neutrophil count   <500/mm3
 

Signs and Symptoms

History:
  1. Onset, duration and pattern of fever
  2. Date of last course of chemotherapy and drugs administered
  3. Associated complaints – stiff neck, rash, cuts or open areas on skin, port-a-cath redness or swelling, earache, sore throat, cold symptoms, cough, nausea/vomiting, abdominal pain, diarrhea, night sweats, chilling, confusion and urinary symptoms.
Physical:
Warm or flushed skin, shivering or chills, sweating, tachycardia, tachypnea, hypotension, appearance of port site, rash, skin exam. Include mouth, throat, lung and abdominal exam.

Evaluations

  1. CBC, with differential
  2. Blood cultures – peripheral and central, aerobic and anaerobic – if indicated
  3. Other tests, as indicated by the history or physical

Treatment Guidelines

  1. NP – consult with physician for all cases of neutropenia fever

  2. Evaluate High vs. Low Risk
    1. Low Risk Complications
      1. Neutropenia expected to last less than 7 to 10 days
      2. Absence of underlying conditions e.g. hypotension, pulmonary compromise, vomiting, significant mucositis, cognitive changes, other serious chronic diseases.
    2. High Risk of Complications
      1. Expected prolonged neutropenia
      2. Presence of underlying conditions as noted above

  3. Initial Choice of Antibiotics
    1. Low Risk – low risk patients who are reliable and have good psychosocial support should be treated on an outpatient basis
      1. Oral ciprofloxacin 500 mg PO every 8 hours for 5-7 days and Augmentin 500 mg PO every 8 hrs for 5 - 7 days.
      2. For patient allergic to penicillin, Clindamycin 300 mg PO every 6 hours for 5-7 days.
      3. Acetaminophen 650-1000 mg every 4 hours as needed.
      4. Daily phone call with patient until afebrile > 24 hours and symptoms resolving.
    2. High Risk
      1. i. Physician referral for hospital admission

From:

  1. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Fever and Neutropenia. Version 1.2005 Myeloid Growth Factors in Cancer Treatment. Version 2.2005.
  2. Telephone Conversation, January 2006. Alfred Lee, Infectious Diseases at Baylor College of Medicine.
  3. Frefield, A, Marchigiani, D, Walsh, T, et al. A double-blind comparison of empirical or oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 1999;341: 305-311.

 

Reviewed: 7/1/04, 1/25/06
Powel Brown, M.D.
Jenny Chang, M.D.
Richard Elledge, M.D.
Mamta Kalidas, M.D.
Rush Lynch, M.D.
Kent Osborne, M
Suzanne Perez, RN, BSN
Mari Rude, RN, ANP