Summary about Disease
Febrile neutropenia is a serious medical condition defined as a fever (usually a single oral temperature of ≥38.3°C [101°F] or a temperature of ≥38.0°C [100.4°F] sustained over one hour) in a patient with neutropenia (an abnormally low count of neutrophils, a type of white blood cell) where the absolute neutrophil count (ANC) is <500 cells/mm3, or <1000 cells/mm3 with a predicted decline to <500 cells/mm3. It indicates a high risk of infection and potentially life-threatening complications. It's commonly seen in patients undergoing chemotherapy, especially for hematologic malignancies, but can occur in other settings as well. Immediate evaluation and empirical antibiotic treatment are crucial.
Symptoms
The primary symptoms are:
Fever (oral temperature ≥38.3°C [101°F] or ≥38.0°C [100.4°F] sustained over one hour).
Chills
Other symptoms may be subtle due to the lack of neutrophils to mount an inflammatory response. These may include:
Sore throat
Mouth sores
Cough
Pain (abdominal, rectal, or at catheter insertion sites)
Diarrhea
Skin rashes or lesions
Causes
The underlying cause is neutropenia, most commonly due to:
Chemotherapy: Many chemotherapy drugs suppress bone marrow function, leading to decreased neutrophil production.
Hematologic malignancies: Leukemia, lymphoma, and myeloma can directly affect neutrophil production.
Bone marrow disorders: Aplastic anemia, myelodysplastic syndromes.
Immunosuppressant medications: Used in transplant recipients or to treat autoimmune diseases.
Infections: Some viral or bacterial infections can temporarily suppress bone marrow function.
Autoimmune disorders: Such as Systemic Lupus Erythematous
Congenital Neutropenia: rare genetic disorders
Medicine Used
Empiric broad-spectrum antibiotics are the mainstay of treatment. Commonly used medications include:
Beta-lactam antibiotics: such as cefepime, ceftazidime, piperacillin-tazobactam, or carbapenems (meropenem, imipenem-cilastatin).
Vancomycin: May be added if there is suspicion of a catheter-related infection, skin infection, pneumonia, or known MRSA colonization.
Antifungal medications: May be added if fever persists after several days of antibiotics, suggesting a possible fungal infection (e.g., fluconazole, voriconazole, amphotericin B).
Granulocyte colony-stimulating factor (G-CSF): Medications like filgrastim or pegfilgrastim may be used to stimulate neutrophil production, although their routine use is controversial.
Is Communicable
Febrile neutropenia itself is not communicable. However, the underlying infection causing the fever may be communicable, depending on the pathogen.
Precautions
Precautions are aimed at preventing infection in neutropenic patients:
Hand hygiene: Frequent and thorough handwashing by the patient, healthcare providers, and visitors.
Protective isolation: Placing the patient in a private room.
Neutropenic diet: Avoiding raw fruits and vegetables, undercooked meats, and other foods that may carry pathogens.
Avoiding contact with sick individuals: Limiting exposure to people with colds, flu, or other infections.
Masks: Wearing masks in public places or when interacting with others.
Hygiene: good personal hygiene (showering daily and oral hygiene)
Avoiding crowds limit exposure to large groups of people
How long does an outbreak last?
Febrile neutropenia is not an outbreak in the traditional sense. It's an individual patient condition. The duration of febrile neutropenia depends on the underlying cause of the neutropenia, the effectiveness of the antibiotic treatment, and the patient's overall health. It can last from a few days to several weeks. The episode resolves when the infection is cleared and the neutrophil count recovers.
How is it diagnosed?
Diagnosis involves:
Temperature measurement: Documented fever (oral temperature ≥38.3°C [101°F] or ≥38.0°C [100.4°F] sustained over one hour).
Complete blood count (CBC) with differential: To determine the absolute neutrophil count (ANC).
Blood cultures: To identify any bacteria or fungi in the bloodstream.
Urine culture: To rule out urinary tract infection.
Chest X-ray: To rule out pneumonia.
Other cultures or imaging studies: Depending on the patient's symptoms and risk factors (e.g., stool culture if diarrhea is present, CT scan if abdominal pain is present).
Physical Examination: to identify sources of infection like skin, catheter sites, mouth
Timeline of Symptoms
The onset of symptoms can be rapid. A typical timeline:
Day 0: Neutropenia develops.
Day 0-?: Fever develops, often abruptly. Other symptoms (chills, fatigue, sore throat) may develop concurrently or shortly after the fever.
Day 1-?: If untreated, complications such as sepsis, pneumonia, or invasive fungal infections can develop quickly.
Treatment: With prompt antibiotic treatment, fever may start to resolve within 48-72 hours. Neutrophil recovery can take several days to weeks, depending on the underlying cause.
Important Considerations
Medical Emergency: Febrile neutropenia is a medical emergency requiring immediate evaluation and treatment.
Risk Stratification: Patients can be categorized into high-risk and low-risk groups based on factors such as the duration of neutropenia, the presence of comorbidities, and the severity of illness. This stratification guides treatment decisions.
Source Control: Identifying and addressing the source of infection (e.g., removing a catheter if it's infected) is critical.
Antibiotic Resistance: Monitoring for antibiotic resistance patterns is essential to ensure appropriate antibiotic selection.
Patient Education: Educating patients about the signs and symptoms of infection, the importance of adhering to precautions, and when to seek medical attention is crucial.
G-CSF Considerations: The decision to use G-CSF should be individualized based on risk factors, clinical status, and institutional guidelines.