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Empiric Antimicrobial Therapy in the Community Hospital Setting for the Cancer Patient with Fever and Neutropenia: The Need for Vigilance and Attention to Detail

  • J. G. Gallagher
Part of the Recent Results in Cancer Research book series (RECENTCANCER, volume 132)

Abstract

The neutropenic patient who becomes febrile has a 60% probability of being infected. With extremely low neutrophil counts (MINGlt;100), the likelihood of bacteremia is approximately 20% (Consensus Panel, Immunocompromised Host Society 1990; Klastersky et al. 1988; Hughes et al. 1990; de Pauw et al. 1990; Pizzo 1989; Hathorn 1989; Lazarus et al. 1989). Untreated or inadequately treated, these infections are often rapidly fatal. The timely and effective treatment of these patients with empiric antibiotics requires attention to detail. Initial evaluation with complete history and physical examination may be lacking important elements when done in settings such as the family doctor’s office or the emergency department of the community hospital. After admission to the community hospital, the patient may be cared for by a private attending physician who sees the patient briefly once daily. If the patient is on a teaching service in a community hospital, the house staff may have varying levels of confidence and experience in dealing with the rapidly evolving syndromes in immunocompromised hosts. Contrast this with the care given in a major university center. The febrile patient is surrounded by house staff and fellows from the departments of hematology, and oncology and infectious diseases. They are customarily enrolled in the in-house sepsis protocol and reevaluated frequently and cultured extensively.

Keywords

Community Hospital Neutropenic Patient House Staff Empiric Antimicrobial Therapy Febrile Neutropenic Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. Consensus Panel, Immunocompromised Host Society (1990) The design, analysis, and reporting of clinical trials on the empirical antibiotic management of the neutropenic patient. J Infect Dis 161: 397–401CrossRefGoogle Scholar
  2. de Pauw BE, Feld R, Deresinski S et al. (1990) Multicentre, randomised comparative study of ceftazidime vs piperacillin + tobramycin as empirical therapy for febrile granulocytopenic patients. Proceedings of the 6th international symposium inf immunocomp host (Abstr 116 )Google Scholar
  3. EORTC International Antimicrobial Therapy Cooperative Group (1991) Single versus multiple daily doses of amikacin combined with ceftriaxone or ceftazidime for empirical therapy of fever in granulocytopenic cancer patients. Proceedings of the 31st interscience conference on antimicrobial Agents and Chemotherapy, p 292Google Scholar
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  5. Hathorn JW (1989) Empirical antibiotics for febrile neutropenic cancer patients. Eur J Cancer Clin Oncol 25 [Suppl 2]: S43–S51PubMedGoogle Scholar
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Further Reading

  1. Consensus Panel, Immunocompromised Host Society (1990) The design, analysis, and reporting of clinical trials on the empirical antibiotic management of the neutropenic patient. J Infect Dis 161: 397–401. A valuable reference to the conduct of clinical trials in this populationCrossRefGoogle Scholar
  2. de Pauw BE, Feld R, Deresinski S et al. (1990) Multicentre, randomised comparative study of ceftazidime vs piperacillin + tobramycin as empirical therapy for febrile granulocytopenic patients. Proc 6th Internat Symp Inf Immunocomp Host (abstr 116 ) A cooperative group trial of monotherapy versus combination treatment. As with the single institution National Cancer Institute trial by Pizzo, a majority of patients in both arms required modification of therapy for successful outcome. Vigilance and frequent reappraisal of the patient are essential in order to modify therapy in a timely fashion.Google Scholar
  3. Hathorn JW (1989) Empirical antibiotics for febrile neutropenic cancer patients. Eur J Cancer Clin Oncol 25[Suppl]:S43–S51 Discusses monotherapy with imipenem or ceftazidime in a single institution.PubMedGoogle Scholar
  4. Hughes WT, Armstrong D, Bodey GP, Feld R, Mandell GL, Meyers JD, Pizzo PA, Schimpff SC, Shenep JL, Wade JC, Young LS, Yow MD (1990) Guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. J Infect Dis 161:381–396 Recommendations regarding initial therapy, changes for persistent fever, duration of antimicrobial therapy, and addition of antifungal therapy. The bibliography and appendices are valuable references.PubMedCrossRefGoogle Scholar
  5. Klastersky J, Zinner SH, Calandra T et al. (1988) Empiric antimicrobial therapy for febrile granulocytopenic cancer patients: lessons from four EORTC trials. Eur J Cancer Clin Oncol 24 [Suppl 1]:S35–S45 An excellent review of the work of the EORTC International Antimicrobial Therapy Cooperative Group over the last 15 years. This group has consistently large numbers of carefully defined compromised hosts in trials of early empiric broad-spectrum antibiotics. Microbiologically documented infections, especially bacteremias, are emphasized as the best test of efficacy for an empiric regimen in severely or persistently neutropenic patients.PubMedGoogle Scholar
  6. Lazarus HM, Creger RJ, Gerson SL (1989) Infectious emergencies in oncology patients. Semin Oncol 16:543–560 An excellent review of the epidemiology of infections in cancer patients and the initial approach to the febrile neutropenic patient.PubMedGoogle Scholar
  7. Pizzo PA (1989) Evaluation of fever in the patient with cancer. Eur J Cancer Clin Oncol 25[Suppl 2]:S9–S16 A good review of the principles of management of the febrile neutropenic episode.PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin · Heidelberg 1993

Authors and Affiliations

  • J. G. Gallagher
    • 1
  1. 1.Department of Hematology/OncologyGeisinger ClinicDanvilleUSA

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