Correspondence
Fever in Patients with Neutropenia
N Engl J Med 1993; 329:1279-1280October 21, 1993
- Article
To the Editor:
Pizzo (May 6 issue)1 recommends careful handwashing before one has any contact with a febrile patient with neutropenia. In a previous review2 he stated that it seemed reasonable to restrict such patients to a cooked-food diet in order to minimize the acquisition of potential pathogens from uncooked fruits and vegetables. Does he still think that a cooked-food diet is indicated? Similarly, should cut flowers be banned from the room of a patient with neutropenia if the sterility of the water in the flower vase cannot be ensured?
2 ReferencesBarton R. Paschal, M.D.
Asheville Hematology and Oncology Associates, Asheville, NC 288011
Pizzo PA . Management of fever in patients with cancer and treatment-induced neutropenia. N Engl J Med 1993;328:1323-1332
Full Text | Web of Science | Medline2
Pizzo PA . Granulocytopenia and cancer therapy: past problems, current solutions, future challenges. Cancer 1984;54:Suppl:2649-2661
CrossRef | Medline
To the Editor:
In Table 3 of his article, Pizzo recommends a change of therapy to “imipenem plus gentamicin or vancomycin” when a gram-negative organism is isolated from the bloodstream during empirical antibiotic therapy in a febrile patient with neutropenia. The only gram-negative organism against which vancomycin is active is Flavobacterium meningosepticum,1 which is not commonly recognized as a pathogen.
As an additional point, a patient with neutropenia and oral ulcerations is at risk for the development of bacteremia with capnocytophaga (DF-1)2.
2 ReferencesJeremy D. Gradon, M.D.
Sinai Hospital of Baltimore, Baltimore, MD 212151
McGowan JE Jr, Del Rio C. Other gram-negative bacilli. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990:1790.
2
Forlenza SW ,Newman MG ,Lipsey AI ,Siegel SE ,Blachman U . Capnocytophaga sepsis: a newly recognised clinical entity in granulocytopenic patients. Lancet 1980;1:567-568
CrossRef | Web of Science | Medline
To the Editor:
Dr. Pizzo overlooked one important issue in his otherwise complete review -- that of therapy for low-risk patients with neutropenia in an ambulatory setting. Not all patients with neutropenia have the same risk of infections or infection-related complications, and low-risk patients can be identified at the onset of their febrile episode1,2. These are predominantly patients with short-lived neutropenia (seven days or less) who become febrile at home, have tumors that respond to antineoplastic chemotherapy, and do not have coexisting morbid conditions, such as hypotension, renal or hepatic insufficiency, or hypercalcemia. We have conducted two trials of outpatient antibiotic therapy in such low-risk patients, comparing an intravenous regimen (aztreonam plus clindamycin) with two oral regimens (ciprofloxacin plus clindamycin in trial 1 and ciprofloxacin plus amoxicillin-clavulanate in trial 2)2,3. The overall response rates for the intravenous and oral regimens in these trials exceeded 85 percent, with little difference between the two regimens. In comparison with in-hospital therapy, outpatient antibiotic therapy is less expensive, is associated with a lower incidence of secondary nosocomial infections and a better quality of life for patients and their families, and uses fewer resources. We think that outpatient therapy should be considered for all low-risk patients with neutropenia and cancer who are febrile.
3 ReferencesKenneth V.I. Rolston, M.D.
Edward B. Rubenstein, M.D.
M.D. Anderson Cancer Center, Houston, TX 770301
Talcott JA ,Siegel RD ,Finberg R ,Goldman L . Risk assessment in cancer patients with fever and neutropenia: a prospective, two-center validation of a prediction rule. J Clin Oncol 1992;10:316-322
Web of Science | Medline2
Rubenstein EB ,Rolston K ,Benjamin RS , et al. Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer. Cancer 1993;71:3640-3646
CrossRef | Web of Science | Medline3
Rolston K, Rubenstein E, Frisbee-Hume S, et al. Outpatient treatment of febrile episodes in low-risk neutropenic cancer patients. In: Program/ Proceedings of the 29th American Society of Clinical Oncology, Orlando, Fla., May 16-18, 1993. Chicago: American Society of Clinical Oncology, 1993:436. abstract.
Author/Editor Response
Dr. Pizzo replies:
To the Editor: Handwashing is the simplest effective means of preventing the transmission of potentially serious pathogens in the hospital. More stringent approaches to controlling the exogenous microbial environment are more cumbersome, and their benefits are harder to define. As inferred by Paschal, when a patient has neutropenia or is receiving antibiotics that alter “colonization resistance,” a cooked-food diet may decrease the likelihood of colonization with the Enterobacteriaceae or pseudomonads that are found on fresh fruits and vegetables. Proving that a cooked-food diet is beneficial, however, is difficult. Thus, it can only be recommended as reasonable. In contrast, the risk of cut flowers to patients with neutropenia, although logical, is one whose deleterious implications have, in my opinion, been overinterpreted. I do not recommend that flowers be prohibited from patients' rooms.
My recommendation for treatment with imipenem, gentamicin, and vancomycin applied to a patient with putative sepsis whose condition is deteriorating despite simpler therapy. Often such patients do not have an immediately definable source of infection, and gram-positive as well as gram-negative sepsis must be considered. I agree with Gradon that capnocytophaga (DF-1) can be a cause of oral infections and bacteremia in immunocompromised hosts, and infection with this organism should be considered in the differential diagnosis.
Rolston and Rubenstein raise the important question of oral therapy for low-risk patients with neutropenia. A few years ago it would have been inconceivable to consider such an approach. As the ability to define low-risk patients improves and broad-spectrum oral-antibiotic therapy becomes more available, ambulatory therapy may become a viable option. It is important, however, not to let recommendations precede definitive data. The studies by Rolston and Rubenstein are certainly a start in the right direction, but confirmatory data are needed before this approach becomes standard practice. I agree that oral therapy is a consideration for a low-risk patient with neutropenia as long as the risks and benefits are carefully reviewed with the patient and hospital-based support is readily available.
Philip A. Pizzo, M.D.
National Cancer Institute, Bethesda, MD 20892
