Management of the Cancer Patient with Fever and Prolonged Neutropenia

Predictors for chemotherapy-related severe or febrile neutropenia: a review of the clinical literature

Purpose. This paper summarizes a literature review of the risk factors and predictors for chemo-therapy-related severe or febrile neutropenia (grades 3 and 4). It explores the extent to which the literature supports the current ASCO guidelines, and assesses the feasibility of developing a predictive algorithm for patients who would benefit from rHuG-CSF (Neupogen).

Methods. An electronic literature search for English articles and abstracts identified 718 abstracts for review. From these, 121 articles were reviewed in depth. The review captured risk factors and predictors for grade 3-4 and/or febrile neutropenia, study design, patient characteristics, chemotherapy treatment, and the incidence of grade 3-4 and/or febrile neutropenia.

Results. Twenty-eight potential risk factors and predictors for severe or febrile neutropenia among cancer patients were identified and could be classified as patient-related, treatment-related, or disease-related characteristics. Some results were inconsistent across studies due to a lack of standardized methods of assessment and reporting. Approximately 1/3 of the factors were mentioned in more than one study and provided information on the statistical significance of findings. Several factors had cross-study support of their value and confirmed previous findings. Strong predictors of severe/febrile neutropenia included advanced age, performance status, myelosuppressive chemotherapy regimen, early low blood counts, the depth of the absolute neutrophil count (ANC) nadir, and a precipitous, early drop in blood counts of all hematopoietic cell types.

Conclusions. This literature review identified several key predictors and risk factors for development of grades 3 and 4 neutropenia in cancer patients. While additional confirmation is needed, there is sufficient consistency in the literature to support use of risk factors to identify patients who may need supportive care. Some of these risk factors were included in the ASCO CSF guidelines for the use of prophylactic support such as G-CSF; however, the ASCO publications have not included other important risk factors, such as age and early reduced ANC levels.

Characterizing extravascular neutrophil migration in vivo in the iris

Extravascular neutrophil migration is poorly characterized in vivo. To test the hypothesis that this migration is a non-random process, we used videomicroscopy to monitor neutrophils in irises of living mice with endotoxin-induced uveitis (EIU). Paths of individual cells were analyzed. Nearly all of these cells were moving in divergent directions, and mean displacement plots indicated that the predominant movement was random. The paths of some cells were fit to bivariate autoregressive integrated moving average models that revealed at least two modes of movement: random search and linear trend. Cell speed was significantly reduced by the actin inhibitor, cytochalasin D. The pattern of migration for neutrophils is in marked contrast to what we previously described for antigen-presenting cells in the iris, but somewhat resembles recent descriptions for T cells within a lymph node. Characterization of extravascular migration of neutrophils has important implications for understanding infection and immunity.

Characterization of neutropenic fever in patients receiving first-line adjuvant chemotherapy for epithelial ovarian cancer

OBJECTIVES

Limited information is available on the incidence and characteristics of neutropenic fever (NF) in patients receiving contemporary regimens for epithelial ovarian cancer (EOC). We examined this issue in patients receiving first-line adjuvant chemotherapy with platinum- and paclitaxel-based regimens at a major cancer institute.

METHODS

Charts of patients with EOC at a single institute from 1998 through 2002 were reviewed. Data were collected on the incidence and duration of NF, duration of hospitalization and fever, cultures, antibiotic and chemotherapy regimen, and type of debulking procedure.

RESULTS

140 patients were treated for EOC. 125 patients received first line chemotherapy. 15 episodes of NF were observed. Mean duration of neutropenia and fever was 2.33 and 3.07 days respectively. 9 of 15 (60%) NF episodes occurred after cycle 1. Cultures were positive in 7 of 15 patients (47%). Organisms most frequently recovered were bowel-derived. 8 patients (53%) had bowel resections, and 15 patients (100%) had radical or supraradical procedures. There was a correlation between incidence of NF and type of procedure (P = 0.01) and stage of EOC (P = 0.04). There was no correlation between NF and elderly age, medical comorbidities, and postoperative complications.

CONCLUSIONS

The rate of NF was higher than previously reported. NF occurred most frequently after cycle 1. NF patients were of advanced stage that had undergone more aggressive surgery and had bowel resections. Our data suggest that patients with advanced EOC who undergo more radical procedures should be identified as high risk for developing NF in early cycles.

Emergency Department evaluation of patients with fever and chemotherapy-induced neutropenia

We sought to describe the common causes of infection in patients presenting to the Emergency Department (ED) with elevated temperature and chemotherapy-induced neutropenia and to determine the frequency with which the ED diagnosis of infection is consistent with the final hospital discharge diagnosis. We performed a structured restrospective chart review of ED patients with fever (T > 38 degrees C) and neutropenia (absolute neutrophil count < 1000/mm(3)) over a 2-year period. Fifty-five episodes of neutropenic fever occurred in 52 patients (mean age 52 years, range 18-86 years; 53% men). Twenty-six patients (47%) were found to have a specific infection identified. Of these, 21/26 (81%; 95% CI, 70-91%) had the source of infection identified while in the ED. All patients who had a focal site of infection identified during their hospitalization were diagnosed in the ED (100%; 95% CI, 86-100%). The other 5 patients, without a source identified in the ED, were found to have bacteremia. The 29 patients without a source identified in the ED were hospitalized and had negative blood and urine cultures and were discharged to home after resolution of fever. A thorough history, physical examination, chest radiograph and urinalysis in the ED identified all patients with a focus of infection. Meticulous ED evaluation of patients with neutropenia and fever may be sufficient to diagnose most sources of infection; however, a significant number of patients without an identifiable focus may have bacteremia.

Predictive value of higher plasma interleukin-6 levels in patients with febrile neutropenia

BACKGROUND

Patients with febrile neutropenia require hospitalization and prompt empirical treatment with broad-spectrum antibiotics. Patients experiencing severe febrile neutropenia episodes need a longer hospitalization period and close follow-up, but those with mild episodes might derive limited benefit from a lengthy hospital stay. This study investigated whether plasma interleukin-6 (IL-6) level has a predictive value in prognosis of febrile neutropenia.

METHODS

Twenty-six patients with various hematologic malignancies with 31 neutropenia episodes were enrolled in the study. Fever developed in 26 patients, 14 clinically severe.

RESULTS

Median plasma IL-6 and serum C-reactive protein (CRP) levels obtained during the first day of febrile episodes were found significantly higher in severe febrile neutropenia episodes compared to mild episodes (median IL-6: 92.5 pg/mL [range 40.0-650.0] vs. 23.3 pg/mL [range 15.0-65.0], p <0.00001; median CRP: 48 mg/dL [range 16-96] vs. 24 mg/dL [range 16-48, p = 0.0]).

CONCLUSIONS

Plasma IL-6 levels may guide to management of febrile neutropenic patients and may be used as predictive factor for poor outcome in these patients.

Infectious morbidity in critically ill patients with cancer

Infection frequently complicates the course of cancer treatment and often adversely affects the outcome. Patients have a greater tendency for acquiring infections caused by opportunistic microorganisms. Agents with low virulence potential may lead to invasive and often life-threatening infections because of altered host immune function. The immune dysfunction may be caused by the underlying malignancy, by antineoplastic chemotherapy, or by invasive procedures during supportive care.

Randomized comparison of cefepime versus ceftazidime monotherapy for fever and neutropenia in children with solid tumors

BACKGROUND

With the availability of new broad-spectrum antibiotics, initial therapy with a single agent has become an alternative to classic combinations, especially beta-lactam antibiotics plus aminoglycosides, in the management of febrile neutropenic cancer patients.

PROCEDURE

Since January 1994, monotherapy has been used for empiric initial treatment at our center. The aim of this prospective randomized study is to compare the efficacy of cefepime (CFP), a new fourth-generation cephalosporin, and ceftazidime (CFZ) as empirical monotherapy of febrile neutropenic patients with solid tumors. From January 1998 to November 1998, 63 episodes of fever and neutropenia occurring in 33 children with solid tumors including lymphomas, were randomized to receive treatment with either CFP or CFZ. The patients were analyzed for leukocyte count and absolute neutrophil count (ANC) at entry, days in fever, neutropenia and hospitalization, and side effects of drugs. Success with or without modifications of the initial antibiotic was defined as survival through neutropenia; failure was death due to infection.

RESULTS

In our study group, with a median age of 7 [(1/12)-14] years, CFP was administered in 32, and CFZ in 31 episodes. An infection was documented microbiologically in eight episodes (25%) in the CFP arm and in nine episodes (29%) in the CFZ arm. The success rate with initial empiric monotherapy was 62.5% in the CFP arm and 61.3% in the CFZ arm respectively (P > 0.05). The total success rate (success with or without modification) was 100% in both arms. No major adverse effects were observed in either groups.

CONCLUSION

CFP is as effective and safe as CFZ for the empirical treatment of febrile episodes in neutropenic patients with solid tumors.

Plasma IL-8 and IL-6 levels can be used to define a group with low risk of septicaemia among cancer patients with fever and neutropenia

The standard therapy for patients with fever and chemotherapy-related neutropenia is hospitalization and infusion of broad-spectrum antibiotics. Early discharge of a defined group of patients at low risk for septicaemia would be of great advantage for these patients. In this study plasma interleukin-8 (IL-8) and interleukin-6 (IL-6) levels measured at start of fever (n = 72) could define a low-risk group of febrile patients with neutropenia due to chemotherapy. For this purpose we collected and analysed data on 72 fever episodes from 53 patients with chemotherapy-related neutropenia, aged between 1 and 66 years. Of the 72 episodes, 18 were classified as bacteraemia and/or clinical sepsis (sepsis group). The IL-6 and IL-8 plasma concentration were significantly increased in patients with chemotherapy-related neutropenia and fever due to bacteraemia versus fever of non-bacterial origin (P = 0.043 and P = 0.022 respectively). Logistic regression analysis, with sepsis as the outcome variable, revealed significant effects of age combined with either IL-6 or IL-8. Sepsis occurrence was lowest for patients <16 years and highest in patients between 16 and 50 years, and was higher in patients with increased IL-6 (P = 0.032) or IL-8 (P = 0.049). No significant effect of leucocyte count, C-reactive protein, sex or underlying malignancy at presentation was detected. The plasma IL-6 and IL-8 levels were fairly strongly correlated (Pearson r = 0.62). Using a cut-off value with 100% sensitivity, both IL-8 and IL-6 could define a low-risk group of neutropenic patients of 28% (CI 15-40%) at the start of the febrile period. Intervention studies are warranted to confirm this result and to investigate whether an early discharge based on IL-8 or IL-6 measurement is safe, increases the quality of life, and results in cost savings.

PCR-restriction enzyme analysis for detection of Candida DNA in blood from febrile patients with hematological malignancies

Blood samples were drawn daily from 72 patients who had hematological malignancies, neutropenia, and fever and who had failed to respond to broad-spectrum antibiotics. Each sample was used for conventional fungal blood cultures and for detection and identification of Candida DNA by a PCR method with subsequent restriction enzyme analysis (REA) recently developed in our laboratory. The PCR method was able to detect five CFU of Candida spp. per ml of blood, and subsequent REA of the amplicons allowed the identification of the Candida species most commonly implicated in cases of candidiasis. Thirty-one patients were PCR-REA positive, and four of these patients were also culture positive. The ultimate diagnosis for 13 of these patients and 1 patient who was PCR-REA negative was disseminated candidiasis (confirmed by clinical data, multiple cultures, histology, autopsy, and/or ultrasonographic evidence of hepatosplenic candidiasis). The molecular method is significantly more sensitive than conventional fungal blood cultures and has a high negative predictive value (97.5%) for the development of disseminated candidiasis in neutropenic patients.

Outpatient antimicrobial protocol for febrile neutropenia: a nonrandomized prospective trial using ceftriaxone, amikacin, and oral adjuvant agents

Broad-spectrum antimicrobial therapy has revolutionized the management of febrile neutropenia (FN) in cancer patients. In vogue is an effective therapy an an outpatient basis. One thousand three hundred episodes of FN observed in 70 pediatric solid tumors (STs) and 65 cases of hematomalignancy (HM) at a median age of 5.5 years were treated with a protocol using once-a-day injectable ceftriaxone plus amikacin and other oral adjuvant antimicrobial agents. The mean duration of FN in the ST group was 4.0 +/- 1.2 days and in the HM group was 5.0 +/- 2.5 days. The mean duration of antimicrobial cover in the ST group was 5.0 +/- 1.75 days and in the HM group was 6.0 +/- 1.5 days. The overall recrudescence rate was 6% and the mean duration to recrudescence was 4 +/- 1.5 days (range 3-6 days). The objectives of this protocol were cost reduction and utilization of the available inpatient resources optimally by reducing the pressures of hospitalization for febrile neutropenia. We concluded that a selected group of patients with FN can be effectively managed with this regimen on an outpatient basis.

Safety of early hospital discharge of selected febrile children and adolescents with cancer with prolonged neutropenia

PROBLEM

The safety of early hospital discharge (i.e., before the absolute neutrophil count [ANC] exceeds 500 cell/mm3) of febrile neutropenic children and adolescents with cancer who had experienced prolonged neutropenia (i.e., for more than 7 days) following admission has not been studied.

METHOD OF STUDY

Three hundred and thirty nine consecutive admissions of children and adolescents with cancer for management of febrile neutropenia were reviewed. Early discharge criteria included absence of fever for 24 hours prior to discharge, sterile blood cultures for 24 hours, evidence of bone marrow recovery defined as a sustained increase in platelet count and ANC or absolute phagocyte count (APC), and control of local infection if present. Children hospitalized with febrile neutropenia who remained neutropenic for more than 7 days were analyzed to assess their outcomes following discharge it they had met criteria for early hospital discharge.

RESULTS

Thirty-three patients in whom neutropenia had persisted for more than 7 days were discharged before attaining an ANC greater than 500/mm3 when they met the early discharge criteria. Only two children (6%) required readmission for recurrent fever, a rate which was not different from that of patients discharged after a more transient episode of neutropenia (2 of 33 vs. 3 of 121, P = 0.3). Both patients who were readmitted had a source of local infection which worsened despite oral antibiotics. Both patients appeared clinically well at the time of readmission and had sterile cultures during their second hospitalization with resolution of local infection.

CONCLUSION

This study confirms that low-risk criteria used to select children with cancer for discharge before complete resolution of neutropenia can be safely applied to those patients whose neutropenia lasted more than 7 days following admission.