This light micrograph shows neutrophils and red blood cells at high magnification.
MP is a 38-year-old woman who comes to the clinic with a temperature of 101F and complains of abdominal pain approximately 14 days after her last chemotherapy treatment.
Results of Last Visit
During her last appointment, MP denied fevers, chills, or other signs/symptoms of infection but, due to laboratory results, was initiated on levofloxacin 750 mg orally once daily as prophylactic therapy.
Relevant Medical History
• Diagnosis of triple-negative breast cancer
• Current therapies include cyclophosphamide and doxorubicin (AC) every 21 days x 4 cycles
• Ten days after receiving her last dose of chemotherapy, her complete blood cell count (CBC) results, showing neutropenia, are shown in Table/Slide 1.
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An assessment for complications associated with severe infection should always be assessed in a patient with cancer who has a documented fever. Risk assessment will direct the management and empirical antibiotic therapy (oral vs. intravenous), setting for management (inpatient vs. outpatient), and treatment duration of the antibiotic. Risk can be formally assessed using the Multinational Association for Supportive Care in Cancer (MASCC) scoring system (Table/Slide 2).
According to the most recent update of the Infectious Diseases Society of America guidelines, published in Clinical Infectious Disease in 2011, a patient is considered high-risk if the criteria listed in Table/Slide 3 are met.
High-risk patients need to be admitted to the hospital for empirical intravenous antibiotic therapy. Overall, monotherapy with an anti-pseudomonal beta-lactam agent, (eg, cefepime), a carbapenem (eg, meropenem or imipenem-cilastatin), or piperacilin-tazobactam is recommended. Other antimicrobials including aminoglycosides, fluoroquinolones, and/or vancomyin may be added to the initial regimen if antimicrobial resistance is suspected or demonstrated, and for management of complications, such as hypotension or pneumonia.
In this case study, the patient meets the high-risk criteria; therefore, an admission to the hospital as well as intravenous cefepime is indicated. Vancomycin is not indicated, as the patient does not meet the criteria for adding vancomycin. The indications for adding vancomycin are summarized in Table/Slide 4.
In this particular patient, levofloxacin, a fluoroquinolone, was used prophylactically; however, cefepime was then used to manage the infection. Therefore, vancomycin is not indicated.
If the patient was low-risk (Table/Slide 5), then the possibility of management on an outpatient basis is feasible.
Freifeld AG, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56-93,