Neutropenia for chemotherapy pts:

Definition
ANC < 500 = neutropenia
ANC < 100 = profound neutropenia
Fever = single temp >101F / 38.3C or sustained temp >100.4 /38c

ANC is the total leukocyte count multiplied by the neutrophil fraction plus bands
ANC = Total WBC x (neutrophil fraction + bands)

-Fever may be the only sign of infection 2/2 lack of clinical signs of inflammation
-Fever + Neutropenia and Chemotherapy or Central Lines = emergency
-25% pts bacteremic (MCC coag-neg staph, less common are gram-neg or fungal infxn)
-High Risk if: high risk if the ANC is < 100/mm3, neutropenia is expected to last more than 7 days, or if hypotension, pneumonia, or neurologic signs are present.

Work up:
-Admit
-Labs: 
--Central Catheter blood culture (from all lumens if a multilumen catheter is present)
--Complete blood count with differential
--CMP
-Further testing dictated by clinical signs and symptoms (CXR, UA, LP, etc...)
-Treat only after Bld Cx but WITHIN 2hrs of presentation
-Start Broad-spectrum intravenous anti-pseudomonal antibiotics (cefepime, meropenem, or piperacillin-tazobactam)

Notes: routine addition of vancomycin is not generally indicated. Antifungal therapy may be added in high-risk patients with fever/neutropenia that does not resolve within 4 to 7 days. Duration of treatment usually depends on recovery, source, and ANC improving to > 500/mm3. If a central catheter-associated bloodstream infection (CLABSI) is suspected, antimicrobial treatment for at least 14 days is indicated and, if complicated, for up to 4 to 6 weeks with consideration of central catheter removal.

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ABP Guidance: 

Fever associated with neutropenia occurs frequently in pediatric patients who have hematologic malignancies and are undergoing chemotherapy. 
Neutropenic patients may lack clinical signs of inflammation but are at risk of rapidly progressive invasive bacterial infections, especially if a central venous catheter is present. As many as 25% of such patients may be bacteremic, most commonly with coagulase-negative staphylococci. Gram-negative infections are less frequent, but are associated with significantly higher mortality, and fungal infections may also occur even less frequently.

 

Neutropenia in the febrile pediatric cancer patient is defined as absolute neutrophil count (ANC) < 500/mm3, with profound neutropenia defined as < 100/mm3. ANC is calculated as total leukocyte count multiplied by the fraction of neutrophils plus bands; it does not include immature cells such as promyelocytes. Fever is defined as a single temperature > 38.3°C/101°F or sustained temperature > 38°C/100.4°F and may be the only sign of infection in the neutropenic child. Patients may be further classified as high risk if the ANC is < 100/mm3, neutropenia is expected to last more than 7 days, or if hypotension, pneumonia, or neurologic signs are present.

 

Initial laboratory evaluation should always include a complete blood count with differential, metabolic panel testing, and central catheter blood culture (from all lumens if a multilumen catheter is present), with further testing dictated by clinical signs and symptoms.

 

All high-risk febrile neutropenic patients must be hospitalized and treated within 2 hours of presentation with broad-spectrum intravenous anti-pseudomonal antibiotics (cefepime, meropenem, or piperacillin-tazobactam) after a central catheter blood culture has been obtained. Despite the prevalence of coagulase-negative staphylococci in these patients, the routine addition of vancomycin is not generally indicated because of minimal impact on morbidity and mortality, and the concern for colonization with vancomycin-resistant enterococci (VRE). Other antimicrobials may be added in cases of severe sepsis, focal infections, mucositis, or hemodynamic instability, or if antimicrobial resistance is likely. Antifungal therapy may be added in high-risk patients with fever/neutropenia that does not resolve within 4 to 7 days. Length of time for treatment usually depends on recovery, source, and ANC improving to > 500/mm3. If a central catheter-associated bloodstream infection (CLABSI) is suspected, antimicrobial treatment for at least 14 days is indicated and, if complicated, for up to 4 to 6 weeks with consideration of central catheter removal.