This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care-associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.

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BACKGROUND Results of previous single center observational studies suggest that daily bathing of patients with chlorhexidine may prevent hospital-acquired bloodstream infections (HABSIs) and acquisition of multidrug-resistant organisms (MDROs). METHODS We conducted a multicenter, cluster randomized, non-blinded crossover trial to evaluate the effect of daily bathing with chlorhexidine impregnated washcloths on the acquisition of MDROs and incidence of HABSIs. Nine intensive care and bone marrow transplant units in 6 hospitals were randomly assigned to bathe patients with either 2% no-rinse chlorhexidine-impregnated or non-antimicrobial washcloths for a six-month period, exchanged for the alternate product during the subsequent six months. The incidence rates of acquisition of MDRO and HABSI rates were compared between the two time periods by Poisson regression analysis. RESULTS A total of 7735 patients were enrolled during the study. The overall MDRO acquisition rate was 21% lower when chlorhexidine bathing was used (5.10 cases per 1000 patient days) than when non-antimicrobial washcloths were used (6.60 cases per 1000 patient days, p=0.028). The overall HABSI rate was 31% lower when chlorhexidine was used (4.45 cases per 1000 patient days) than when non-antimicrobial cloths were used (6.60 cases per 1000 patient days, p=0.007) No serious skin reactions were noted in either study period. CONCLUSIONS Daily bathing with chlorhexidine-impregnated washcloths significantly reduced the risk of acquiring MDROs and developing HABSI.

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In the next decade, longer survival of patients with cancer and more-aggressive therapies applied to common conditions, such as asthma and rheumatoid arthritis, will result in a larger population with significant immune system defects. Many in this population will be at risk for opportunistic infections, which are familiar to doctors who have treated people infected with human immunodeficiency virus (HIV). However, the epidemiology, presentation, and outcome of these infections in patients with an immune system defect, other than that caused by HIV infection, may be different than those encountered in patients with acquired immunodeficiency syndrome. Reviewed are 4 common opportunistic infections: Pneumocystis carinii pneumonia, cryptococcosis, atypical mycobacterial infection, and cytomegalovirus infection. Emphasized are the important differences among these groups at risk.