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Febrile neutropenia

What's new

Updated 2023 ASCO guidelines for the management of febrile neutropenia in pediatric patients with cancer.

Background

Overview

Definition
FN is a common consequence of cancer chemotherapy characterized by fever and underlying infection.
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Pathophysiology
FN is caused by antineoplastic therapy (side-effect leading to myelosuppression or mucositis) in cancer patients.
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Disease course
Clinical manifestations of FN include fever, underlying infection associated with bacteremia, sepsis, hemodynamic instability, and death.
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Prognosis and risk of recurrence
The 30-day mortality associated with FN ranges from 6% to 10%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of febrile neutropenia are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2023,2018), the Infectious Diseases Society of America (IDSA/ASCO 2018), the European Society of Medical Oncology (ESMO 2016), and the Infectious Diseases Society of America (IDSA 2011)....
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Screening and diagnosis

Indications for screening: as per ASCO/IDSA 2018 guidelines, Assess the risk of FN (in consultation with infectious disease specialists as needed) systematically, taking into account the following factors:
Situation
Guidance
Patient-related factors
Advanced age
Performance status
Nutritional status
Prior episode of FN
Comorbidities
Cancer-related factors
Cancer diagnosis
Cancer stage
Remission status
Cancer treatment response
Treatment-related factors
Cytotoxic regimen
Dose intensity
Degree and duration of gastrointestinal and/or oral mucositis
Degree and duration of cytopenia
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  • Diagnostic criteria

Classification and risk stratification

Risk assessment, general principles: as per IDSA 2011 guidelines, Assess the risk of severe infectious complications as part of the initial evaluation of patients with FN.
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  • Risk assessment (scores)

Diagnostic investigations

Clinical assessment: as per ASCO 2018 guidelines, Assume that fever in a patient with neutropenia from cancer therapy is the result of an infection in the absence of an alternative explanation. Attempt to establish clinical and microbiologic diagnoses that may affect antibacterial choice and prognosis.
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  • Routine laboratory tests

  • Microbiological cultures

  • Respiratory virus testing

  • Chest imaging

Medical management

Setting of care, outpatient: as per ASCO 2018 guidelines, Use clinical judgment when selecting candidates for outpatient management.
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  • Setting of care (inpatient)

  • Setting of care (discharge)

  • Antibiotic therapy (low-risk patients)

  • Antibiotic therapy (high-risk patients)

  • Antibiotic therapy (modifications)

  • Antibiotic therapy (duration)

  • Antifungal therapy (low-risk patients)

  • Antifungal therapy (high-risk patients)

  • Antiviral therapy

  • G-CSFs

Specific circumstances

Pediatric patients, risk assessment: as per ASCO 2023 guidelines, Adopt a validated risk stratification strategy and incorporate it into routine clinical management.
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  • Pediatric patients (diagnostic evaluation)

  • Pediatric patients (antibiotic therapy, low-risk patients)

  • Pediatric patients (antibiotic therapy, high-risk patients)

  • Pediatric patients (antibiotic therapy, modification and discontinuation)

  • Pediatric patients (antifungal therapy, biomarkers)

  • Pediatric patients (antifungal therapy, low-risk patients)

  • Pediatric patients (antifungal therapy, high-risk patients)

  • Patients with central venous catheters

Preventative measures

Infection prevention
As per ASCO/IDSA 2018 guidelines:
Ensure that all healthcare workers comply with hand hygiene and respiratory hygiene/cough etiquette guidelines to reduce the risk for aerosol- and direct or indirect contact-based transmission of pathogenic microorganisms in the healthcare setting.
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Advise outpatients with neutropenia from cancer therapy to avoid prolonged contact with environments that have high concentrations of airborne fungal spores (such as construction and demolition sites, intensive exposure to soil through gardening or digging, or household renovation).
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  • Influenza vaccination

  • Antibiotic prophylaxis

  • Antifungal prophylaxis

  • Antiviral prophylaxis

  • G-CSFs