Paucis Verbis: Neutropenic fever in cancer patients

A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

• Temperature 39 C
• BP 160/80
• HR 60
• RR 14
• Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

• Is this patient “high” or “low” risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
• Does this person require inpatient admission?
• What antibiotics would you start on this patient?

Answers

• The patient’s MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
• NOTE: “Burden of febrile neutropenia” is a subjective scoring of the patient’s symptoms
• The patient is, however, ultimately HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
• Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

PV Card: Neutropenic Fever in Cancer Patients (IDSA 2010)

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Alissa and Hemal for suggesting the topic!

Reference

1. Freifeld A, Bow E, Sepkowitz K, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011;52(4):e56-93. [PubMed]

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