MKSAP Quiz: Hospitalization for neutropenic fever
A 45-year-old man is hospitalized for neutropenic fever. He was recently diagnosed with diffuse large B-cell lymphoma, and his last chemotherapy treatment was 10 days ago. What is the most appropriate management to reduce the risk of future febrile neutropenia?
A 45-year-old man is hospitalized for neutropenic fever. He was recently diagnosed with diffuse large B-cell lymphoma, and his last chemotherapy treatment was 10 days ago. His course of chemotherapy consisted of rituximab, cyclophosphamide, doxorubicin, vincristine (day 1), and prednisone (days 1-5). He is treated appropriately with a broad-spectrum antibiotic and is discharged 5 days later feeling improved and with a recovering neutrophil count.
Which of the following is the most appropriate management to reduce the risk of future febrile neutropenia?
A. Reduce cyclophosphamide and doxorubicin doses
B. Start granulocyte colony-stimulating factor (G-CSF) weekly
C. Start G-CSF at the time of chemotherapy
D. Start levofloxacin at the time of chemotherapy
MKSAP Answer and Critique
The correct answer is C. Start G-CSF at the time of chemotherapy. This content is available to MKSAP subscribers as Question 13 in the Hematology section. More information about MKSAP is available online.
The patient should start granulocyte colony-stimulating factor (G-CSF) with his next cycle of chemotherapy (Option C). Febrile neutropenia is defined as a single fever of 38.3 °C (101 °F) or sustained fever of 38 °C (100.4 °F) in a patient with a current or anticipated absolute neutrophil count less than 500/μL (0.5 × 109/L). Chemotherapy-induced neutropenia typically occurs within 5 to 15 days following chemotherapy. G-CSF and granulocyte-macrophage colony-stimulating factor can be given prophylactically to patients receiving chemotherapy that carries a high risk of neutropenia and as secondary prophylaxis in patients with a previous episode of febrile neutropenia. G-CSF administered on day 2 of the next chemotherapy cycle should reduce the risk of another neutropenic fever episode. G-CSF is not indicated for most patients with neutropenia who are afebrile, as a routine adjunct to empiric antibiotics for patients presenting with febrile neutropenia, or for patients undergoing induction chemotherapy for acute leukemia.
Reducing this patient's chemotherapy dose for subsequent cycles would not be an appropriate strategy (Option A). Prophylaxis with G-CSF is better management for this patient than chemotherapy dose reduction, which might compromise the potential therapeutic outcome of his treatment.
Given the cost, lack of benefit in patients with recovered neutrophil counts, and potential adverse effects, weekly administration of G-CSF is not warranted (Option B). G-CSF has many potential toxicities, including transient leukopenia following administration; systemic reactions that may include flulike symptoms, hypertension, and increased risk for thrombosis; possible stimulation of malignancy; and production of neutralizing antibodies.
Fluoroquinolone prophylaxis is typically used for patients at high risk for prolonged neutropenia (Option D). Those at high risk include patients undergoing allogeneic stem cell transplantation or receiving induction chemotherapy for acute leukemia, neither of which applies to this patient.
Key Points
- Granulocyte colony-stimulating factor can be given prophylactically to patients receiving chemotherapy that carries a high risk of neutropenia and as secondary prophylaxis in patients with a previous episode of febrile neutropenia.
- Granulocyte colony-stimulating factor is not indicated for most patients with neutropenia who are afebrile, as a routine adjunct to empiric antibiotics for patients presenting with febrile neutropenia, or for patients undergoing induction chemotherapy for acute leukemia.