Paucis Verbis: Neutropenic fever in cancer patients

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?

Answers:

• 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
• The patient is 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.

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Thanks to Alissa and Hemal for suggesting the topic!

Reference
Friefeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93. Pubmed
.