New approaches to management of fever and neutropenia in high-risk patients

Abstract

Purpose of reviewPatients receiving treatment for acute leukaemia and haematopoietic cell transplantation (HCT) have prolonged neutropenia and are at high risk of neutropenic fever, with bacterial and particularly invasive fungal infections as feared complications, possessing potentially serious consequences including intensive care admission and mortality. Concerns for these serious complications often lead to long durations of broad-spectrum antimicrobial therapy and escalation to even broader therapy if fever persists. Further, the default approach is to continue neutropenic fever therapy until count recovery, leaving many patients who have long defervesced on prolonged antibiotics. Recent findingsThis article details recent progress in this field with particular emphasis on early discontinuation studies in resolved neutropenic fever and improved imaging techniques for the investigation of those with persistent neutropenic fever. Recent randomized controlled trials have shown that early cessation of empiric neutropenic fever therapy is well tolerated in acute leukaemia and autologous HCT patients who are clinically stable and afebrile for 72 h. Delineation of the best approach to cessation (timing and/or use of fluoroquinolone prophylaxis) and whether this approach is well tolerated in the higher risk allogeneic HCT setting is still required. Recent RCT data demonstrate utility of FDG-PET/CT to guide management and rationalize antimicrobial therapy in high-risk patient groups with persistent neutropenic fever.

Usefulness of 18F-FDG PET-CT in the Management of Febrile Neutropenia: A Retrospective Cohort from a Tertiary University Hospital and a Systematic Review

“…Another benefit that 18 F-FDG-PET-CT provides is its potential to detect dissemination of infection, especially in cases of IFI. Several articles state that 18 F-FDG-PET-CT may have greater sensitivity than conventional tests to detect dissemination and occult lesions in the context of IFI [ 1 , 4 , 22 ]. In the analysis of our data, 18 F-FDG-PET-CT was key in the diagnosis of disseminated fungal disease in one of the patients, which led to changes in therapeutic management.…”

“…Febrile neutropenia (FN) is a common complication of cancer, particularly in patients with hematological malignancies who receive high-intensity chemotherapy or stem cell transplantation (SCT) [ 1 ]. In this setting, infections are an important complication and cause significant morbidity and mortality.…”

“…Although several authors have reviewed the existing literature [ 1 , 4 , 6 , 7 , 8 ], to our knowledge, there is not a comprehensive and systematic review on this topic.…”

What Do We Know About the Usefulness of 18f-fdg Pet-ct for the Management of Invasive Fungal Infection? An International Survey.

“…In recent years, the contribution of 18 F-FDG PET-CT to the management of infectious complications in hematological patients has been studied [4][5][6]. Several studies suggest that 18 F-FDG PET-CT has the potential of improving the evaluation of patients with febrile neutropenia (FN) and invasive fungal infection (IFI) and also the assessment of the response to treatment [4,[7][8][9][10].…”

“…In recent years, the contribution of 18 F-FDG PET-CT to the management of infectious complications in hematological patients has been studied [4][5][6]. Several studies suggest that 18 F-FDG PET-CT has the potential of improving the evaluation of patients with febrile neutropenia (FN) and invasive fungal infection (IFI) and also the assessment of the response to treatment [4,[7][8][9][10]. On the other hand, it is known that the use of excessively broad-spectrum empirical therapies in febrile immunocompromised patients may lead to adverse effects, increasing antimicrobial resistance and unnecessary expenses; therefore, several authors have analyzed the usefulness of 18 F-FDG PET-CT for optimizing empirical antimicrobial therapy and allowing early de-escalation and withdrawal of antimicrobials, and speci cally antifungals [5,7,11,12,13].…”