Management of the febrile neutropenic patient

Fever of unknown origin in oncological patients is a frequent problem throughout the world. The microbiology of infections in these patients can vary widely. Gram-negative bacteria were more prevalent in early trials, but Gram-positive organisms have become increasingly common since the mid 1980s. However, Gram-negative microorganisms appear to be resurging. Equally important changes have occurred in the antimicrobial susceptibility of infective pathogens, most importantly methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, vancomycin-resistant enterococci, viridans group streptococci, ciprofloxacin-resistant Escherichia coli and Pseudomonas aeruginosa. Current management strategies for febrile neutropenic patients emphasize risk assessment and the suitability of individual patients for outpatient versus hospital treatment and for oral versus parenteral therapy. Among the new determinants of infection risk, the most important are the severity and duration of neutropenia. Additional significant issues include: the selection of monotherapy versus combination therapy; and prophylaxis, which involves, among other strategies, quinolone use, prevention of fungal and viral infections, surveillance cultures, prevention of catheter-related infections, and vaccines. With relation to the consensus document, it should clearly define fever and neutropenia, and rank the strength of recommendations and the quality of the evidence on which they are based. Finally, the document should provide a detailed, stepwise management algorithm, addressing the initial empirical antimicrobial therapy and the antimicrobial therapy on days 3-5 and days 5-7 of therapy.