Neutropenic Fever

Author: OncoLink Team
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What is neutropenia?

Neutropenia is a low neutrophil count. A neutrophil is one type of white blood cell in our body. White blood cells (WBC) are one part of our body's immune system, working to protect us against infection. Neutrophils are the "first responders" and quickly appear at the site of infection. They ingest and kill foreign particles like bacteria. They can be found in the pus of a wound and play a role in sudden inflammation (redness, warmth, swelling, and pain).

A low neutrophil count (less than 1,000) is known as neutropenia. The lower the neutrophil count, the higher the risk of infection. Neutropenia is most often caused by cancer therapies, such as chemotherapy and radiation therapy. Ask your healthcare team when your counts are likely to be at their lowest (also called nadir), as you will most likely be at home during the nadir. For chemotherapy, low counts most often happen 7-10 days after treatment.

A neutropenic patient at home should check his or her temperature twice a day at about the same time each day.

What is a neutropenic fever?

Neutropenic fever is a fever while a patient is neutropenic. A fever in a neutropenic patient is a temperature of or greater than 100.4°F or 38.0°C. An infection can happen with minimal signs in a neutropenic patient because they do not have the white blood cells to start an inflammatory response. Many times a fever is the only sign of an infection. 

A neutropenic fever is an emergency in a cancer patient. Patients with neutropenia are unable to fight infection. This is due to a low number of neutrophils. An infection can quickly turn into sepsis and become life threatening. Along with the fever, the patient may have chills and rigors (shaking). 

Management

If you have a fever of or greater than 100.4°F or 38.0°C, you need to call your provider right away. Intravenous (IV) antibiotics should be given very quickly with a neutropenic fever to stop progression to sepsis. Broad-spectrum antibiotics are used because they treat many types of infections. 

When a patient has a neutropenic fever, a full infection work-up will be done. This involves: a chest x-ray, blood cultures, urine studies, checking the central line, checking the skin and, if the patient is presenting with any specific infectious symptoms, those will also be tested. For example, if a patient has a fever, stomach pain and loose stools, an abdominal (belly) CT scan may be ordered and stool (bowel movement) studies taken. If any of the studies show the likely reason for the fever, more specific antibiotics will be given. A medication such as acetaminophen will be given to “break” the fever. When a fever “breaks” or resolves, a patient may sweat heavily.

If a patient has a fever for more than 24 hours, the infection work-up may be repeated. It may be done every 24 hours until the patient no longer has a fever. A source of infection is often not found in neutropenic patients, but it is important to continue to treat with antibiotics until the patient is no longer having fevers and is no longer neutropenic. Once the patient is no longer neutropenic, antibiotics may be stopped and, if the patient does not have a fever for 24 hours, the patient is safe to be discharged to home. If a source of infection was found, the patient will finish the course of antibiotic treatment.

While neutropenic, there are steps you can take to help prevent a neutropenic fever:

  • Hand washing. This includes the patient and those around the patient.
  • Don't go into large crowds where you may come into contact with germs, such as shopping malls, church, or public transit. If need be, go at off peak hours to skip the crowds.
  • Do not be around anyone who is sick (including colds), even those you live with.
  • Avoid children or adults who have recently received vaccines.
  • Do not handle animal waste (cat litter, bird cage, fish tank water, chicken coops, etc.)
  • If you have a central catheter (PICC, Port, Hickman), be careful to keep it clean and dry. Check the area for redness or soreness daily.
  • Follow a mouth care routine.
  • Wear sunscreen (SPF 15 or higher) to prevent sunburn.
  • Use only electric razors to avoid cuts that can become infected.
  • Be careful to avoid any cuts or injuries. Skip contact sports and wear gloves for household chores.
  • Do not use rectal suppositories.
  • Do not have dental work without first talking with your healthcare team.
  • Do not get any vaccines without first talking with your healthcare team.
  • Women should not use tampons while neutropenic as these can pose a risk of infection and toxic shock syndrome. Use sanitary napkins instead.
  • Neutropenic patients should not have sex, any type of vaginal or anal penetration (such as toys/props) or oral sex as these can pose an infection risk. Talk with your healthcare providers if you have sexual practices that you are worried about.

Practice Food Safety

  • Wash all fresh fruits and vegetables well before consuming.
  • Avoid raw or rare-cooked meat and fish. Meat should be cooked to established safe internal temperatures.
  • Use only pasteurized eggs, milk, yogurt, cheese, other dairy products, fruit juices, and honey.
  • Avoid soft mold-ripened and blue-veined cheese: Brie, Camembert, Roquefort, Stilton, Gorgonzola, Bleu.
  • Hot dogs, lunch meats, and deli meats should be reheated to steaming hot or 165 degrees.
  • Abide by sell by or use by dates.
  • Avoid buffets, salad bars and self-serve bulk containers.
  • Follow these 4 basic steps to food safety:
    • Clean - Wash your hands well before preparing any food and keep your work space clean.
    • Separate - Don’t cross-contaminate. Keep raw meat and poultry apart from cooked foods.
    • Cook - Use a food thermometer to be sure meat and poultry are safely cooked.
    • Chill - Refrigerate or freeze food at once.

When to contact your care team

A neutropenic fever is an emergency! If you develop any signs or symptoms of infection, you should call your provider right away.

Signs and symptoms of infection to look for:

  • Check your temperature twice a day or if you feel feverish. If your temperature is above 100.4, call your provider right away.
  • Do not take acetaminophen (Tylenol) or aspirin to lower the fever without talking to your provider first.
  • Shaking chills.
  • Cough, sore throat, shortness of breath.
  • Burning with urination or new lower back pain.
  • Blood in urine.
  • Diarrhea (worsening) or change in the odor of your stool.
  • Rash, redness, or swelling of the skin.
  • Redness, soreness around central line catheter, feeding tube, or a wound.
  • Soreness or swelling in your mouth or throat, ulcers or white patches in your mouth, or a change in the color of your gums.

A fever or infection in a neutropenic patient is an emergency. Make sure that you have a phone number for use during office hours and an emergency phone number for your provider’s office during non-business hours. They should be kept near a home phone or can be programmed into a cellular phone. Do not wait to call your provider and follow instructions given to you as to how to proceed. 

References

Abeloff M, Niederhuber JE, Armitage JO, Doroshow, JH, Kastan MB, Tepper, JE. Abeloff’s Clinical Oncology. 5th edition. Philadelphia: Churchill Livingstone; 2014.

Chan S, Chadwick J, Young D, Holmes E, Gotlib J. Intensive serial biomarker profiling for the prediction of neutropenic fever in patients with hematologic malignancies undergoing chemotherapy: a pilot study. Hematology Reports. 2014:6(2).

Centers for Disease Control. Neutropenia and Risk for Infection. Found at: https://www.cdc.gov/cancer/preventinfections/pdf/neutropenia.pdf

Gunalp M, Koyunoglu M, Gurler S, Koca A, Yesilkaya I, Oner E, Akkas M, Aksu NM, Demirkan A, Polat O, Elhan AH. Independent factors for prediction of poor outcomes in patients with febrile neutropenia.  Medical Science Monitor. 2014:20,1826-1832. 

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