Evaluation

Patients that meet the criteria for febrile neutropenia require urgent evaluation. The purpose of initial evaluation is twofold: (1) assess for the presence and site of infection and (2) determine the risk of significant infection-related complications. Evaluation begins with a thorough history and meticulous physical examination. Among immunocompromised patients, the classic signs and symptoms of infection are unreliable. A complete head-to-toe examination should be undertaken wherein every minor finding suspicious as a site or route of infection is investigated further. The gastrointestinal tract, lungs, skin, mouth, and pharynx deserve special consideration since endogenous flora originating from these sites account for the majority of neutropenic infections (Marchetti and Calandra 2004; Crawford et al. 2004). Careful evaluation of surgical scars, biopsy sites and venous catheter sites, if present, should also be made. The perineum and perianal region are often overlooked sites of infection that require careful inspection and palpation.

The initial laboratory evaluation includes a CBC and differential, electrolytes, BUN, creatinine, liver function studies, as well as cultures of blood (two sites) and urine. Sputum, cerebral spinal fluid, skin lesions, and stool should also be cultured if there is clinical suspicion of infection involving these sites. Most recommend obtaining a plain chest radiograph in all patients regardless of clinical findings. Ambulatory patients without clinical signs of pulmonary infection do not routinely require imaging of the chest because it is often of low diagnostic yield (Oude Nijhuis 2003; Sipsas et al. 2005). Laboratory and radiologic examinations maybe insensitive markers of infection in the setting of neutropenia. As an example, up to 89 % of febrile neu-tropenic patients with urinary tract infection lack py-uria and 40 % of patients with pneumonia will have no abnormal findings on chest radiography.

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