Published online Aug 25, 2016. doi: 10.5495/wjcid.v6.i3.37
Peer-review started: July 6, 2015
First decision: September 30, 2015
Revised: April 25, 2016
Accepted: June 1, 2016
Article in press: June 3, 2016
Published online: August 25, 2016
Febrile neutropenia (FN) is responsible for significant morbidity and mortality. It can also be the reason for delaying or changing potentially effective treatments and generates substantial costs. It has been recognized for more than 50 years that empirical administration of broad spectrum antibiotics to patients with FN was associated with much improved outcomes; that has become a paradigm of management. Increase in the incidence of microorganisms resistant to many antibiotics represents a challenge for the empirical antimicrobial treatment and is a reason why antibiotics should not be used for the prevention of neutropenia. Prevention of neutropenia is best performed with the use of granulocyte colony-stimulating factors (G-CSFs). Prophylactic administration of G-CSFs significantly reduces the risk of developing FN and consequently the complications linked to that condition; moreover, the administration of G-CSF is associated with few complications, most of which are not severe. The most common reason for not using G-CSF as a prophylaxis of FN is the relatively high cost. If FN occurs, in spite of prophylaxis, empirical therapy with broad spectrum antibiotics is mandatory. However it should be adjusted to the risk of complications as established by reliable predictive instruments such as the Multinational Association for Supportive Care in Cancer. Patients predicted at a low level of risk of serious complications, can generally be treated with orally administered antibiotics and as out-patients. Patients with a high risk of complications should be hospitalized and treated intravenously. A short period of time between the onset of FN and beginning of empirical therapy is crucial in those patients. Persisting fever in spite of antimicrobial therapy in neutropenic patients requires a special diagnostic attention, since invasive fungal infection is a possible cause for it and might require the use of empirical antifungal therapy.
Core tip: The overall presentation of febrile neutropenia has considerably changed over the last 50 years. Prevention is now feasible with the use of granulocyte colony stimulating factors. If fever appears in a neutropenic patient, empirical therapy with broad spectrum antibiotics is mandatory; it should be adapted to the risk of severe complications that can be now predicted in individual patients using a reliable scoring system. Special situations such as persisting fever in neutropenic patients, the risk of invasive fungal infection and the management of older patients are crucial questions that are discussed as well as the issues linked to the high cost of prophylaxis and therapy.