Febrile Neutropenia
Febrile Neutropenia
Febrile Neutropenia
JULIUS A. LECCIONES, MD
Executive Director
Philippine Children’s Medical Center
Quezon Avenue, Quezon City
Febrile Neutropenia in Children
With Cancer
Characteristics Weight
Patient- and disease-related AML, Burkitt's lymphoma 2 points for central venous
factors induction ALL, progressive catheter; 1 point for age ≤
None
disease, relapsed with marrow 5 years
involvement
Episode-specific factors Absolute monocyte count Hypotension, tachypnea/hypoxia 4.5 points for clinical site of
< 94%, new CXR changes, infection; 2.5 points for no
altered mental status, severe URTI; 1 point each for fever
mucositis, vomiting or > 38.5°C, hemoglobin ≤ 70
abdominal pain, focal infection, g/L
other clinical reason for
inpatient treatment
Rule information Absolute monocyte count ≥ Absence of any risk factor, low Total score <6, low risk of
100/uL, low risk of risk of serious medical serious infectious
bacteremia; HSCT, high risk complication, HSCT, high risk complication; HSCT, high
risk
Patient- and disease-related Relapsed leukemia, Bone marrow involvement, 4 points for chemotherapy
factors chemotherapy within 7 central venous catheter, pre-B- more intensive than ALL
days of episode cell leukemia maintenance
Episode-specific factors CRP ≥ 90 mg/L, hypotension Absence of clinical signs of viral 5 points for hemoglobin ≥
platelets ≤ 50g/L infection, CRP > 50 mg/L, 90 g/L; 3 points each for
WBC ≤ 500/uL, hemoglobin > WBC < 300/uL, platelets
100 g/L < 50 g/L
Rule information Zero risk factors, only low Three or fewer risk, factors, low Total score < 9, low risk of
platelets, or only < 7 days risk of significant infection; adverse FN outcome;
from chemotherapy, low HSCT, high risk HSCT, high risk
risk of invasive bacterial
infection
Abbreviations: AML, acute myeloid leukemia; ALL, acute lymphoblastic leukemia; CRP, C-reactive protein; CXR, chest radiograph; FN, fever and
neutropenia; HSCT, hematopoietic stem-cell transplantation; URTI, upper respiratory tract infection.
* Valid refers to clinically adequate discrimination of a group at low risk of complications.
Initial Management of Febrile
Neutropenia: Risk Stratification
Consistent with largely adult-focused IDSA guideline
Pediatric studies: depth of leukopenia or thrombocytopenia
examined rather than anticipation of prolonged neutropenia in
predicting which patients are not at higher complication risk
No single rule is clearly effective or reliable than others, nor
does it allow recommending different rules for predicting
specific outcomes
Cessation of Treatment
• All patients: Discontinue empiric antibiotics in
patients who have negative blood cultures at 48
hours, who have been afebrile for at least 24 hours,
and who have evidence of marrow recovery (1C)
Risk Stratification:
Patients at high risk of IFD: AML or relapsed acute
leukemia, receiving highly myelosuppressive
chemotherapy for other malignancies, and those
undergoing allogeneic HSCT with persistent fever
despite prolonged (≥ 96 hours) broad-spectrum
antibiotic therapy and expected prolonged
neutropenia (> 10 days); all others should be
categorized as IFD low risk (1B)
IFD Evaluation
All patients: Consider galactomannan in bronchoalveolar lavage and
cerebrospinal fluid to support diagnosis of pulmonary or CNS
aspergillosis (2C)