Initially the patient should have a complete physical examination, including careful scrutiny of the oropharynx, nares, external auditory canals, skin and axilla, groin, perineum, and rectal area. The exit site and subcutaneous tunnel of any indwelling vascular catheter should be examined closely for erythema and palpated for tenderness and expression of purulent material. Perirectal abscess is a potentially serious infection in neutropenic hosts, with tenderness and erythema that may be the only clues to infection. Any presumptive infection identified during the evaluation should direct appropriate cultures and tailor anti-infective therapy.
Treatment should be provided as appropriate for focal infections identified by physical examination or diagnostic imaging. Select low-risk patients may be managed as outpatients. Empirical treatment of fever and neutropenia without an identified source should include an extended-spectrum penicillin or cephalosporin with activity against gram-negative bacilli, including P. aeruginosa, sometimes in combination with an aminoglycoside (Fig. 120-1). If the patient has an indwelling vascular catheter, vancomycin should be added because of the increasing prevalence of methicillin-resistant S. aureus but can be discontinued if S. aureus is not cultured after 48 to 72 hours. Specific antibiotic regimens should be guided by local antibiotic resistance patterns at each institution.
No source of infection identified Empirical anti-infective therapy Fever (38.5C) and neutropenia (granulocytes <500/mm3) Focal infection Specific therapy directed against most likely pathogens
Figure 120-1 Initial management of fever and neutropenia without an identified source in cancer and transplant patients. (From Conrad DA: Patients with cancer. In Jenson HB, Baltimore RS, editors: Pediatric Infectious Diseases: Principles and Practice, ed 2, Philadelphia, 2002, Saunders, p 1161.)
If no microbiologic cause is isolated, empirical broad-treatment with amphotericin B or another antifungal agent spectrum antibiotics are continued as long as the patient is instituted in patients who have neutropenia and persistent remains neutropenic, regardless of whether the fever resolves fever without a focus, despite broad-spectrum antibacterial (Fig. 120-2). Antibiotic therapy should be modified as indi-therapy for approximately 5 days (see Fig. 120-2).cated by new findings or if the patient’s clinical status deterio-The use of recombinant granulocyte colony-stimulating rates. Further investigation for fungal infection and empirical factor or granulocyte-macrophage colony-stimulating factor plus Add: If: plus Substitute: If:
Figure 120-2 Continuing management of possible infection after 7 days of fever without an identified source in cancer and transplant patients. (From Conrad DA: Patients with cancer. In Jenson HB, Baltimore RS editors: Pediatric Infectious Diseases: Principles and Practice, ed 2, Philadelphia, 2002, Saunders, p 1165.)
Chapter 120 u Infection in the Immunocompromised Person 393 stimulates neutrophil production by the bone marrow, reduces the duration and severity of neutropenia, and decreases the risk of infection. Some chemotherapeutic protocols for the treatment of solid tumors that result in prolonged neutropenia incorporate hematopoietic cytokine therapy as part of the treatment protocol.