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Increased susceptibility to infection in patients with cancer is due to impaired defense mechanisms, the myelosuppressive and immunosuppressive effects of chemotherapy, or some combination of these
In patients with neutropenia, infection is a medical emergency
Fever
Defined as a single temperature of > 38.3°C (101°F) or a temperature of > 38°C (100.4°F) for > 1 hour
Although sometimes attributable to other causes, fever must be assumed to be due to an infection
The bacterial organisms accounting for the majority of infections in cancer patients include
Gram-positive bacteria (coagulase-negative Staphylococcus, Staphylococcus aureus, Streptococcus pneumoniae, Corynebacterium, and streptococci)
Gram-negative bacteria (Escherichia coli, Klebsiella, Pseudomonas, Enterobacter)
Gram-positive organism infections are more common but gram-negative infections are more serious and life threatening
The risk of bacterial infections rises when the neutrophil count is < 500/mcL (0.5 × 109/L); the risk markedly increases when the count falls below 100/mcL (0.1 × 109/L) or when there is a prolonged duration of neutropenia, typically > 7 days
Patients with cancer are at higher risk for infection with SARS-CoV-2 and for more severe cases of COVID-19 infection and its complications
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Routine digital rectal examinations are generally avoided unless symptoms suggest a rectal abscess or prostatitis
If a rectal examination is necessary, antibiotics should be administered first
Appropriate cultures (eg, blood, sputum, urine, cerebrospinal fluid) and COVID-19 testing should always be obtained
Two sets of blood cultures should be drawn before starting antibiotics
If the patient has an indwelling catheter, one of the cultures should be drawn from the line
Chest radiograph should also be obtained
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Initiate therapy immediately in the febrile, neutropenic patient
The choice of antibiotics depends on the patient's clinical status and any localizing source of infection
If the patient is clinically well despite the fever, monotherapy with an intravenous β-lactam with anti-Pseudomonas activity should be started
Cefepime
Ceftazidime
Imipenem/cilastatin
Piperacillin/tazobactam
If the patient is clinically ill with hypotension or hypoxia in addition to the fever, an intravenous aminoglycoside or fluoroquinolone should be added
If there is a strong suspicion of a gram-positive organism, such as from S aureus catheter infection, intravenous vancomycin can be given
The Infectious Disease Society of America (IDSA) has published recommendations for outpatient antibiotic use in low-risk febrile patients with neutropenia
Patients must have an expected neutropenic timeframe of ≤ 7 days
Patients must not have comorbidities or signs of
Hemodynamic instability
Gastrointestinal dysfunction
Altered mental status
Pulmonary problems (infiltrate, hypoxia, or underlying chronic obstructive pulmonary disease)
Liver or kidney disease or impairment
Patients should receive initial doses of empiric antibacterial therapy within 1 hour of being seen and monitored for at ...