Management of febrile neutropenic patients

Infection is the most common complication of febrile neutropenia. Bacterial infections predominate during the early stages of a neutropenic episode,whereas invasive fungal infections tend to occur later. Prompt initiation of antimicrobial agents remains the gold standard. The recent cumulative data indicate a low-risk group that is unlikely to progress to a grave clinical condition. In the Japanese guideline updated in 2003, the patients at low risk of complications are determined initially, and the patients at low risk can receive oral fluoroquinolones with or without amoxicillin/clavulanate. A high-risk group, however,must be given vigorous parenteral treatment with 4 th-generation cephalosporins or carbapenems with or without an aminoglycoside. Initial empirical therapy should be based on local epidemiology and drug-susceptibility patterns. Antimicrobial coverage against Pseudomonas species is necessary. If defervescence occurs in 3-5 days or fever persists with a stable condition, the same agents could be continued. If fever persists with no improvement in conditions, an aminoglycoside is added to patients on monotherapy as an initial therapy. Changing the Beta-lactams is considered for patients on combination therapy with Beta-lactams plus an aminoglycoside. Fungal cultures and serological test are performed. After 48 hours of observation on the treatment, antifungals are then started depending on the results of culture and serological tests. Chemoprophylaxis should be considered for patients at high risk.