A 34-year-old male with recently diagnosed Hodgkin lymphoma is admitted to the hospital for induction chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine. On day 7 of the induction, he develops fever as high as 38.4°C and rigors. His blood pressure is 80/52 mm Hg, heart rate is 110 beats/min, respiratory rate is 22 breaths/min, and his oxygen saturation is 92% on 4 L O2 via nasal canula. He is given 2 L of lactated Ringer’s after which his blood pressure improves to 98/64. Internal jugular central line site is examined, and no erythema or purulence at the site of insertion is noted. Labs are notable for:
Which of the following interventions is MOST likely to decrease this patient’s mortality?
A. Vancomycin and cefepimeCorrect Answer: A
This patient has neutropenic fever which is a serious complication of chemotherapy. It is defined by an isolated temperature >38.3°C (101°F) or a temperature of >38.0°C (100.4°F) lasting for >1 hour in a patient with neutropenia. If not treated promptly, sepsis and septic shock can develop. Severe neutropenia is defined as an absolute neutrophil count (ANC) of less than 500 cells/mm3 . Neutrophils prevent bacterial and fungal infections; therefore, neutropenic patients are especially prone to these types of infections.
Adequate antibiotic therapy is the key intervention to decrease mortality of this patient. The initial empiric antibiotic therapy for febrile neutropenia is a beta-lactam with pseudomonas coverage (such as ceftazidime, cefepime, piperacillin-tazobactam) or a carbapenem (meropenem, imipenem). While vancomycin is not typically a part of the empiric antibiotic regimen, it should be added in patients with evidence of hemodynamic instability (such as in this patient), pneumonia, skin or soft tissue infection, or catheter-related infection. Vancomycin or alternative gram-positive coverage may be discontinued at 48 hours if there is no confirmation of gram-positive pathogens. Antibiotic therapy should be further tailored to resistance patterns of bacteria previously isolated from a patient and colonization with resistant organisms such as methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum β-lactamase (ESBL) gram-negative organisms, or carbapenemase-producing organisms.
Patients should be evaluated for the presence of indwelling lines both as a source of infection and for removal depending on the isolated pathogen. In this clinical scenario, immediate removal of central line is not indicated. In patients that are considered to be high risk for infectious complications (hospitalized at the time of fever, age >65 years, expected protracted neutropenia lasting >10 days, or ANC <100/µL, sepsis, pneumonia, or invasive fungal infections), administration of granulocyte colonystimulating factor should be considered. Neutropenic precautions alone would not be sufficient to decrease this patient’s mortality.
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