Congress Abstracts 2006

121

UNDERSTANDING THE TREATMENT OF NEUTROPENIC FEVERS IN PATIENTS WITH HEMATOLOGIC MALIGNANCIES. Laura Adams, MSN, RN-C, ANP, WHNP, Ohio State University Arthur G. James Cancer Hospital, Columbus, OH.

Neutropenia is a common toxicity of therapy for hematologic malignancies. It is defined as <500 neutrophils/mm³ or <1,000 neutrophils/mm³ with a predicted decrease to <500 neutrophils/mm³. Infections occurring during neutropenia are a leading cause of morbidity and mortality. The National Comprehensive Cancer Network (NCCN) and Infectious Disease Society of America (IDSA) have established guidelines for treatment and evaluation of patients with neutropenia who develop fever defined as a single oral temperature >= 38.3ºC or a temperature >= 38.0ºC persistent over one hour.

Research over the last 20 years has demonstrated that infections with gram-positive organisms have become more commonly implicated than those with gram-negative organisms. Recent treatment recommendations reflect this data and include coverage for gram-positive organisms to prevent sepsis.

A side-by-side comparison was made between the NCCN and IDSA guidelines for neutropenic fever therapy in high-risk patients. High risk is defined as <500 neutrophils/mm³ or an anticipated fall to this level. Both guidelines recommend intravenous antibiotics. Both recommend mono- or dual therapy with or without vancomycin, depending on specific situations. Acceptable monotherapies are extended spectrum antipseudomonal cephalosporins or broad-spectrum carbapenems. NCCN differs in which piperacillin/tazobactam is recommended for monotherapy. Recommended dual therapies include an aminoglycoside with a carbapenem, an extended-spectrum cephalosporins, or an antipseudomonal-penicillin with or without vancomycin. Because vancomycin resistant enterococcus (VRE) has become more common, both agencies include criteria for the inclusion of vancomycin. Anti-fungal coverage is recommended for persistent fever over 3-5 days without yield of specific organisms. Therapy is recommended until Absolute Neutrophil Count (ANC) is > 500 or as recommended for isolated organisms.

The NCCN and IDSA neutropenic fever therapy guidelines were established by extensive research and clinical analysis. Understanding these recommendations allows for continuity of care among high-risk patients.

When fever arises during neutropenia, it is important to begin appropriate antibiotics, selected on a case-by-case basis within established guidelines. The NCCN and IDSA guidelines should be utilized with consideration of institutional guidelines, patient history and presentation, and anti-microbial susceptibility patterns within an individual institution.