A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:
- Temperature 39 C
- BP 160/80
- HR 60
- RR 14
- Oxygen saturation 99% on room air
His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.
- Is this patient “high” or “low” risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
- Does this person require inpatient admission?
- What antibiotics would you start on this patient?
- The patient’s MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
- NOTE: “Burden of febrile neutropenia” is a subjective scoring of the patient’s symptoms
- The patient is, however, ultimately HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
- Abx = Cefipime + Vancomycin
FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.
PV Card: Neutropenic Fever in Cancer Patients (IDSA 2010)
Adapted from  Go to ALiEM (PV) Cards for more resources.
Thanks to Alissa and Hemal for suggesting the topic!
- Freifeld A, Bow E, Sepkowitz K, 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. [PubMed]