This article, prepared by the Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guidelines Panel, updates guidelines established a decade ago by the Infectious Disease Society of America for the use of antimicrobial agents to treat neutropenic patients with unexplained fever [1].
DefinitionsFever is defined as a single oral temperature of у38.3ЊC (101ЊF) or a temperature of у38.0ЊC (100.4ЊF) for у1 h. Neutropenia is defined as a neutrophil count of !500 cells/mm 3 , or a count of !1000 cells/mm 3 with a predicted decrease to !500 cells/mm 3 .
Initial EvaluationDetermine whether the patient is at low risk for complications; determine whether vancomycin therapy is needed.
Initial Antibiotic TherapyOral route. For low-risk adults only; use ciprofloxacin plus amoxicillin-clavulanate.Monotherapy with vancomycin not indicated.
The 2005 Update Committee agreed unanimously that reduction in febrile neutropenia (FN) is an important clinical outcome that justifies the use of CSFs, regardless of impact on other factors, when the risk of FN is approximately 20% and no other equally effective regimen that does not require CSFs is available. Primary prophylaxis is recommended for the prevention of FN in patients who are at high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. CSF use allows a modest to moderate increase in dose-density and/or dose-intensity of chemotherapy regimens. Dose-dense regimens should only be used within an appropriately designed clinical trial or if supported by convincing efficacy data. Prophylactic CSF for patients with diffuse aggressive lymphoma aged 65 years and older treated with curative chemotherapy (CHOP or more aggressive regimens) should be given to reduce the incidence of FN and infections. Current recommendations for the management of patients exposed to lethal doses of total body radiotherapy, but not doses high enough to lead to certain death due to injury to other organs, includes the prompt administration of CSF or pegylated G-CSF.
This is the first in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of these guidelines is to provide assistance to clinicians when making decisions on treating the conditions specified in each guideline. The targeted providers are internists, pediatricians, and family practitioners. The targeted patients and setting for the fever and neutropenia guideline are hospitalized individuals with neutropenia secondary to cancer chemotherapy. Panel members represented experts in adult and pediatric infectious diseases and oncology. The guidelines are evidence-based. A standard ranking system was used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary, algorithms, and tables highlight the major recommendations. The guideline will be listed on the IDSA home page at http://www.idsociety.org.
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