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Critical care clinics 16 granulocytopenia

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  • Granulocytopenia is defined as a reduced number of blood granulocytes, namely neutrophils, eosinophils, and basophils. The term granulocytopenia is often used synonymously with neutropenia . Agranulocytosis refers to a complete absence of neutrophils in peripheral blood. Neutropenia is the primary focus of this article.
  • Granulocytopenia (neutropenia) is defined specifically as a decrease in the number of circulating neutrophils in the nonmarginal pool, which constitutes 4-5% of total body neutrophil stores. Most of the neutrophils are contained in the bone marrow, either as mitotically active (one third) or postmitotic mature cells (two thirds).
  • Age, race, genetic background, environment, and other factors can influence the neutrophil count. The lower limit of the absolute neutrophil count (ANC) in adults is 1800/mm3, but for practical purposes, a value of less than 1500/mm3 is used to define neutropenia.
  • Neutropenia is classified as mild, moderate, or severe, based on the ANC, which is calculated by multiplying the total white blood cell (WBC ) count by the percentage of neutrophils plus the band forms of neutrophils in the differential. Mild neutropenia is present when the ANC is 1000-1500/mm3, moderate neutropenia is present with an ANC of 500-1000/mm3, and severe neutropenia refers to an ANC of less than 500/mm3.
  • Neutropenia can be caused by insufficient or injured bone marrow stem cells, shifts in neutrophils from the circulating pool to the marginal blood or tissue pools, increased destruction in the circulation, or a combination of these mechanisms. Intravascular stimulation of neutrophils by plasma-activated complement 5 (C5a) and endotoxin may cause increased margination along the vascular endothelium, decreasing the number of circulating neutrophils. The term pseudoneutropenia refers to neutropenia caused by increased margination.
  • Disorders of the pluripotent myeloid stem cells and committed myeloid progenitor cells, which cause decreased neutrophil production, include some congenital forms of neutropenia, aplastic anemia , acute leukemia, and myelodysplastic syndrome . Other examples include bone marrow tumor infiltration, radiation, infection (especially viral), and bone marrow fibrosis. Cancer chemotherapy, other drugs, and toxins may damage hematopoietic precursors by directly affecting bone marrow.
  • Peripheral loss of neutrophils can occur during infection and by immunologic destruction triggered by autoimmune diseases (eg, Felty syndrome) and by drugs acting as haptens. The risk of serious infection increases as the ANC falls to the severely neutropenic range (<500/mm3). The duration of severe neutropenia directly correlates with the total incidence of all infections and those infections that are life threatening.
  • Bacterial organisms most often cause fever and infection in neutropenic patients. Historically, gram-negative aerobic bacteria (eg, Escherichia coli , Klebsiella species, Pseudomonas aeruginosa ) have been most common in these patients. However, gram-positive cocci, especially Staphylococcus species and Streptococcus viridans , have emerged as the most common pathogens in fever and sepsis because of the increasing use of indwelling right atrial catheters.
  • After treating neutropenic patients with broad-spectrum antibiotics for several days, superinfection with fungi is common. Candida species are the most frequently encountered organisms in this setting.
  • Frequency United States The incidence rate of neutropenia was studied in New York City in 2008 in 261 healthy women aged 20-70 years of varying ethnicity.7 The incidence rate was 10.5% among US blacks. American and European white individuals and those from the Dominican Republic had a 0% incidence rate. Other ethnic groups included those from Haiti, 8.2% incidence rate; Barbados/Trinidad-Tobago, 6.4%; and Jamaica, 2.7%.7 Race Race and genetic background can influence the neutrophil count. Blacks, Ethiopians, Yemenite Jews, and certain populations in the world could have lower ANCs due to lower WBC counts. Data from US National Health and Nutritional examination 1999 to 2004 survey showed the prevalence of neutropenia was 4.5% among black participants relative to 0.79% in white individuals and 0.38% in Mexican-Americans participants.8   Blacks have a lower neutrophil count either due to defective granulocyte release from normal bone marrow, or they may have a compromised bone marrow reserve. Age Age can influence the neutrophil count.
  • History Hallmarks of significant neutropenia are fever and recurrent infection, primarily of the oropharynx and skin. Obtaining a careful drug history is important. Common presenting symptoms of neutropenia Low-grade fever Sore mouth Odynophagia Gingival pain and swelling Skin abscesses Recurrent sinusitis and otitis Symptoms of pneumonia (eg, cough, dyspnea) Perirectal pain and irritation
  • Congenital neutropenia – This condition is suggested by a personal history of lifelong infections, family history of recurrent infections, and limited survival. Chronic, benign familial neutropenia – This condition is suggested by a history of long-standing neutropenia without an increased risk of infection. These patients do not generate increased leukocyte counts with infection, but they have fevers and other symptoms, such as tachycardia, when infected.
  • Physical Physical findings on examination of a patient with neutropenia may include the following: Fever Stomatitis Periodontal infection Cervical lymphadenopathy Skin infection Splenomegaly
  • Acquired neutropenia (disorder of neutrophil production) Intrinsic bone marrow diseases Aplastic anemia Hematologic malignancy (eg, leukemia, lymphoma, myelodysplasia, myeloma ) Ionizing radiation Tumor infiltration Granulomatous infection Myelofibrosis Drugs, including, but not limited to, the following: Acetaminophen Aminoglutethemide Antithyroid drugs: propylthiouracil, carbimazole, methimazole Cytotoxic chemotherapeutic agents Gold salts Chloramphenicol Indomethacin Phenylbutazone Phenothiazines Semi-synthetic penicillins Cephalosporins Antituberculosis drugs Trimethoprim/sulfamethoxazole Anticonvulsants Cimetidine Clonazepam Ranitidine Ibuprofen Hydralazine Captopril, enalapril Tocainide Chlorpropamide Benzodiazepines Ticlopidine Zidovudine Sulfasalazine Propranolol Digoxin Ticlopidine
  • Acquired neutropenia (peripheral destruction of neutrophils is usually immune mediated) Alloimmune neutropenia in the neonate usually reflects a transplacental transfer of maternal alloantibodies to neutrophil antigens present on the neutrophils of the fetus. Drug immune-mediated neutropenia Aminopyrine Quinidine Cephalosporins Penicillins Sulfonamides Phenothiazines Phenylbutazone Hydralazine Other medications have been implicated. Autoimmune neutropenia may be associated with the following: Crohn disease Rheumatoid arthritis (with or without Felty syndrome) Sjogren syndrome Chronic, autoimmune hepatitis Hodgkin lymphoma Systemic lupus erythematosus Thymoma Goodpasture disease Wegener granulomatosis Pure red blood cell (RBC) aplasia – In this disorder, there is complete disappearance of granulocyte tissue from the bone marrow. Pure RBC dysplasia is a rare disorder due to the presence of antibody-mediated, granulocyte-macrophage colony forming unit (GM-CFU) inhibitory activity, and it is often associated with thymoma . Transfusion reactions – The surface antigens of neutophilia can cause transfusion reactions. Recipients of repeated granulocyte transfusions could become alloimmunized (see image below).
  • Pure red blood cell (RBC) aplasia – In this disorder, there is complete disappearance of granulocyte tissue from the bone marrow. Pure RBC dysplasia is a rare disorder due to the presence of antibody-mediated, granulocyte-macrophage colony forming unit (GM-CFU) inhibitory activity, and it is often associated with thymoma. Transfusion reactions – The surface antigens of neutophilia can cause transfusion reactions. Recipients of repeated granulocyte transfusions could become alloimmunized .
  • Acquired neutropenia (shifts of neutrophils from the circulating to the marginated pool of neutrophils) Bacterial infection Cardiopulmonary bypass Hemodialysis Splenic sequestration Sepsis Congenital neutropenia Cyclic neutropenia Cartilage-hair hypoplasia syndrome Chediak-Higashi syndrome Dyskeratosis congenita Infantile genetic agranulocytosis ( Kostmann syndrome ) Lazy leukocyte syndrome Myelokathexis Shwachman -Diamond syndrome Reticular dysgenesis Eosinopenia may be associated with the following: Acute bacterial infection Glucocorticoid administration Hypogammaglobulinemia Physical stress Thymoma Decreased circulating basophils may be associated with the following: Anaphylaxis Acute infection Drug-induced hypersensitivity Congenital absence of basophils Hemorrhage Hyperthyroidism Ionizing radiation Neoplasia Ovulation Urticaria Drugs (eg, corticosteroid, adrenocorticotropic hormone [ACTH] therapy, chemotherapeutic agents, thyroid hormones)
  • Laboratory Studies Previous to a major workup, rule out infectious and drug-induced causes of neutropenia; then, obtain the following laboratory studies: Complete blood cell (CBC) count Differential WBC count Platelet count Wright-stained peripheral smear: Associated anemia and/or thrombocytopenia and the presence of immature leukocyte precursors on peripheral smear suggest a hematologic malignancy (see images below).
  • Microcytic anemia.
  • Examination of the peripheral smears in immune thrombocytopenic purpura often shows giant platelets. These platelets reflect the increased megakaryocytic mass in the marrow.
  • Imaging Studies Perform long-bone radiographs if a form of congenital neutropenia is suspected. Obtain liver-spleen radionuclide scans if the presence of splenomegaly and splenic sequestration are suspected in a patient with neutropenia. This study also allows evaluation of hepatocellular function and colloid shift, which occurs when hypersplenism is caused by cirrhosis with portal hypertension .
  • Other Tests Obtain vitamin B-12 and folate levels to evaluate for nutritional deficiency and pernicious anemia in individuals with neutropenia. If a patient with neutropenia presents with fever, perform an infection workup, including blood cultures for anaerobic and aerobic organisms. Obtain 2 sets of blood cultures, 10-15 minutes apart, from the peripheral veins and each port of a catheter if the patient has central venous access. Other laboratory studies used for a complete fever workup include the following: Urinalysis Urine culture and sensitivity Culture of wound or catheter discharge Stool for Clostridium difficile Skin biopsy, if new erythematous and tender skin lesions are present Broad-spectrum antibiotics should be started within 1 hour of cultures.
  • Procedures Concurrent anemia, thrombocytopenia, and/or an abnormal result on a peripheral blood smear from a patient with neutropenia suggest an underlying hematologic disorder. In this setting, perform a bone marrow aspiration and obtain a biopsy from the posterior iliac crest. Cytogenetic analysis and cell-flow analysis of the aspirate may be indicate Bone marrow biopsy helps to exclude metastatic carcinoma, lymphoma, granulomatous infection, and myelofibrosis. If mycobacterial or fungal infection is suspected, the aspirate can be cultured.
  • Medical Care Discontinue drugs if they are suspected as the causative agents of neutropenia. Corticosteroid therapy could be effective in immune-mediated neutropenia. Correct nutritional deficiency (cobalamin or folic acid deficiency) if detected.
  • Treat the fever as an infection, as follows9,10,11,12,13,14,15,16,17 : Third-generation cephalosporins (eg, ceftazidime, cefepime) or imipenem-cilastatin and meropenem can be used as a single agent. Gentamicin or another aminoglycoside should be added if the neutropenic patient's condition is unstable or the individual appears septic. Beta-lactam antibiotics (eg, ticarcillin, piperacillin) are usually used in combination with a third-generation cephalosporin or an aminoglycoside. Vancomycin should be added if methicillin-resistant Staphylococcus aureus or Corynebacterium species is suspected. If the neutropenic patient's fever does not respond within 4-5 days or if the fever recurs with the administration of broad-spectrum antibiotics after an initial afebrile interval, consider adding empiric antifungal coverage with amphotericin B (preferably lipid formulation), a broad-spectrum azole (eg, voriconazole), or an echinocandin (eg, caspofungin).
  • Fever in patients with low-risk neutropenia can be treated on an outpatient basis with oral antibiotics. In some studies, low-risk patients have been defined as patients whose cause of neutropenia is known; who are hemodynamically stable; who have an expected duration of neutropenia of less than 7 days, whose tumor is under control; and who are without any comorbid conditions, nausea, vomiting, or mucositis. Fluoroquinolones (eg, ciprofloxacin, ofloxacin) are oral antibiotics that are used frequently, either alone or in combination with amoxicillin-clavulanate or clindamycin.
  • Myeloid growth factors, granulocyte colony-stimulating factors (GCSFs), and granulocyte-macrophage colony-stimulating factor (GM-CSFs) may shorten the duration of neutropenia in patients who have undergone chemotherapy. GCSFs are lineage-specific for the production of functionally active neutrophils and can also be used in patients with severe, chronic neutropenia. GM-CSFs stimulate the production of neutrophils, monocytes, and eosinophils. Filgrastim and pegfilgrastim are examples of GCSFS; sargramostim is an example of a GM-CSF. These agents are typically administered no sooner than 24 hours after chemotherapy completion.
  • Neutrophil (granulocyte) transfusion, although disappearing from clinical practice, has some clinical usefulness in treating neonatal sepsis. Its use in adults with neutropenia, in whom adequate increments of WBC counts are difficult to achieve, has not been demonstrated in randomized clinical trials.18 Granulocyte transfusion could be considered in cases of gram-negative sepsis with no improvement in 24-48 hours.
  • Cyclic neutropenia patients have recurrent mouth infections, usually present in childhood; GCSF has been effective treatment. Congenital neutropenia patients could have recurrent severe infections and could be treated successfully with growth factors. Important supportive measures Careful handwashing before and after direct contact with patients with neutropenia Meticulous care of indwelling venous catheters and avoidance of urinary catheters and other invasive maneuvers that violate natural infection barriers
  • Surgical Care In individuals with neutropenia and Felty syndrome who have recurrent life-threatening bacterial infections, splenectomy is the treatment of choice. Indwelling central venous catheters should be removed in febrile neutropenic patients if septic thromboembolism is suspected. Other indications for catheter removal include the following: Corynebacterium jeikeium infection Infection with Candida species Polymicrobial infection Persistent fevers Pocket-space abscess Tunnel infections

Critical care clinics   16 granulocytopenia Critical care clinics 16 granulocytopenia Presentation Transcript

  • Granulocytopenia Critical care clinics Dr Pratyush Chaudhuri
    • Granulocytopenia is defined as a reduced number of blood granulocytes, namely neutrophils, eosinophils, and basophils.
  • Granulocytopenia (neutropenia) is defined specifically as
    • A decrease in the number of circulating neutrophils in the nonmarginal pool, which constitutes 4-5% of total body neutrophil stores.
    • Value of less than 1500/mm3 is used to define neutropenia.
    • Neutropenia is classified as mild, moderate, or severe, based on the ANC, which is calculated by
      • Absolute Neutrophil count= [Total WBC X N% ] + band forms
    • Mild neutropenia - 1000-1500/mm3
    • moderate neutropenia - 500-1000/mm3
    • severe neutropenia - less than 500/mm3.
  • Neutropenia can be caused by
    • insufficient or injured bone marrow stem cells
    • shifts in neutrophils from the circulating pool to the marginal blood or tissue pools
    • increased destruction in the circulation
    • combination of these mechanisms.
    • Intravascular stimulation of neutrophils by plasma-activated complement 5 (C5a) and endotoxin may cause increased margination along the vascular endothelium, decreasing the number of circulating neutrophils.
    • The term pseudoneutropenia refers to neutropenia caused by increased margination.
  • Pathophysiology
    • Disorders of the pluripotent myeloid stem cells and committed myeloid progenitor cells include some congenital forms of neutropenia
      • aplastic anemia
      • acute leukemia
      • myelodysplastic syndrome.
  • Other examples include
    • bone marrow tumor infiltration
    • Radiation
    • infection (especially viral)
    • bone marrow fibrosis.
    • Cancer chemotherapy, other drugs, and toxins may damage hematopoietic precursors by directly affecting bone marrow.
    • immunologic destruction triggered by autoimmune diseases (eg, Felty syndrome) and by drugs acting as haptens.
    • The risk of serious infection increases as the ANC falls to the severely neutropenic range (<500/mm3).
    • The duration of severe neutropenia directly correlates with the total incidence of all infections and those infections that are life threatening.
  • Bacterial organisms most often cause fever and infection in neutropenic patients.
    • gram-negative aerobic bacteria (eg, Escherichia coli , Klebsiella species, Pseudomonas aeruginosa )
    • gram-positive cocci, especially Staphylococcus species and Streptococcus viridans .
  • Note
    • After treating neutropenic patients with broad-spectrum antibiotics for several days, superinfection with fungi is common.
    • Indian Data awaited
    • Data from US National Health and Nutritional examination 1999 to 2004 survey showed the prevalence of neutropenia was
      • 4.5% among black participants relative to 0.79% in white individuals and 0.38% in Mexican-Americans participants.
  • History
    • Hallmarks of significant neutropenia are fever and recurrent infection, primarily of the oropharynx and skin. Obtaining a careful drug history is important.
    • Common presenting symptoms of neutropenia
      • Low-grade fever
      • Sore mouth
      • Odynophagia
      • Gingival pain and swelling
      • Skin abscesses
      • Recurrent sinusitis and otitis
      • Symptoms of pneumonia (eg, cough, dyspnea)
      • Perirectal pain and irritation
    • Congenital neutropenia –
      • personal history of lifelong infections
      • family history of recurrent infections
      • limited survival.
    • Chronic, benign familial neutropenia –
      • long-standing neutropenia without an increased risk of infection.
  • Physical findings on examination of a patient with neutropenia may include the following:
    • Fever
    • Stomatitis
    • Periodontal infection
    • Cervical lymphadenopathy
    • Skin infection
    • Splenomegaly
    • Associated petechial bleeding
    • Perirectal infection
    • Growth retardation in children
  • Acquired neutropenia (disorder of neutrophil production)
    • Intrinsic bone marrow diseases
      • Aplastic anemia
      • Hematologic malignancy (eg, leukemia, lymphoma, myelodysplasia, myeloma )
      • Ionizing radiation
      • Tumor infiltration
      • Granulomatous infection
      • Myelofibrosis
  • Drugs, including, but not limited to, the following:
      • Acetaminophen
      • Aminoglutethemide
      • Antithyroid drugs: propylthiouracil, carbimazole, methimazole
      • Cytotoxic chemotherapeutic agents
      • Gold salts
      • Chloramphenicol
      • Indomethacin
      • Phenylbutazone
      • Phenothiazines
      • Semi-synthetic penicillins
      • Cephalosporins
      • Antituberculosis drugs
      • Trimethoprim/sulfamethoxazole
      • Anticonvulsants
      • Cimetidine
      • Clonazepam
      • Ranitidine
      • Ibuprofen
      • Hydralazine
      • Captopril, enalapril
      • Tocainide
      • Chlorpropamide
      • Benzodiazepines
      • Ticlopidine
      • Zidovudine
      • Sulfasalazine
      • Propranolol
      • Digoxin
      • Ticlopidine
  • Infection, including, but not limited to, the following:
    • Bacterial sepsis
    • Viral infections (eg, influenza, measles, Epstein Barr virus [EBV], cytomegalovirus [CMV], viral hepatitis , human immunodeficiency virus [HIV]-1)
    • Toxoplasmosis
    • Brucellosis
    • Typhoid
    • Tuberculosis
    • Malaria
    • Dengue fever
    • Rickettsial infection
    • Babesiosis
  • Acquired neutropenia (disorder of neutrophil production)
    • Idiopathic
    • Nutritional deficiency
      • (eg, vitamin B-12, folate, copper, cachexia and debilitated states)
  • Acquired neutropenia (disorder of neutrophil production)
    • Acquired neutropenia (peripheral destruction of neutrophils is usually immune mediated)
    • Alloimmune neutropenia in the neonate usually reflects a transplacental transfer of maternal alloantibodies to neutrophil antigens present on the neutrophils of the fetus.
  • Drug immune-mediated neutropenia
      • Aminopyrine
      • Quinidine
      • Cephalosporins
      • Penicillins
      • Sulfonamides
      • Phenothiazines
      • Phenylbutazone
      • Hydralazine
      • Other medications have been implicated.
  • Autoimmune neutropenia may be associated with the following:
      • Crohn disease
      • Rheumatoid arthritis (with or without Felty syndrome)
      • Sjogren syndrome
      • Chronic, autoimmune hepatitis
      • Hodgkin lymphoma
      • Systemic lupus erythematosus
      • Thymoma
      • Goodpasture disease
      • Wegener granulomatosis
      • Pure red blood cell (RBC) aplasia.
      • Transfusion reactions.
      • Large granular lymphocyte proliferation or leukemia
  • Acquired neutropenia (shifts of neutrophils from the circulating to the marginated pool of neutrophils)
    • Bacterial infection
    • Cardiopulmonary bypass
    • Hemodialysis
    • Splenic sequestration
    • Sepsis
    • Congenital neutropenia
    • Cyclic neutropenia
    • Cartilage-hair hypoplasia syndrome
    • Chediak-Higashi syndrome
    • Dyskeratosis congenita
    • Infantile genetic agranulocytosis ( Kostmann syndrome )
    • Lazy leukocyte syndrome
    • Myelokathexis
    • Shwachman -Diamond syndrome
    • Reticular dysgenesis
  • Eosinopenia may be associated with the following:
    • Acute bacterial infection
    • Glucocorticoid administration
    • Hypogammaglobulinemia
    • Physical stress
    • Thymoma
    • Decreased circulating basophils may be associated with the following:
    • Anaphylaxis
    • Acute infection
    • Drug-induced hypersensitivity
    • Congenital absence of basophils
    • Hemorrhage
    • Hyperthyroidism
    • Ionizing radiation
    • Neoplasia
    • Ovulation
    • Urticaria
    • Drugs (eg, corticosteroid, adrenocorticotropic hormone [ACTH] therapy, chemotherapeutic agents, thyroid hormones)
  • Differential diagnosis
    • Acute Lymphoblastic Leukemia Influenza Acute Myelogenous Leukemia Myelodysplastic Syndrome Agranulocytosis Myelophthisic Anemia Aplastic Anemia Neutropenia Bone Marrow Failure Paroxysmal Nocturnal Hemoglobinuria Brucellosis Pernicious Anemia
    • Cytomegalovirus Sepsis, Bacterial Ehrlichiosis Splenomegaly Felty Syndrome Systemic Lupus Erythematosus Folic Acid Deficiency Toxoplasmosis Hairy Cell Leukemia Tuberculosis Hepatitis, Viral Wegener Granulomatosis Infectious Mononucleosis
  • Other Problems to Be Considered
    • Autoimmune diseases Chronic myelomonocytic leukemia Congenital neutropenia Cyclic neutropenia Drug-induced neutropenia Large granular lymphocytic leukemia Pseudoneutropenia
  • Work up
    • Laboratory Studies
    • Previous to a major workup, rule out infectious and drug-induced causes of neutropenia; then, obtain the following laboratory studies:
      • Complete blood cell (CBC) count
      • Differential WBC count
      • Platelet count
      • Wright-stained peripheral smear
  •  
  •  
  • The following studies are applicable in some patients with neutropenia:
    • Antinuclear antibody (ANA)
    • Rheumatoid factor (RF)
    • Serum immunoglobulin (Ig) studies
    • Liver function tests (LFTs)
  • Imaging Studies
    • Perform long-bone radiographs if a form of congenital neutropenia is suspected.
    • Obtain liver-spleen radionuclide scans if the presence of splenomegaly and splenic sequestration are suspected in a patient with neutropenia .
  • Other Tests
    • Obtain vitamin B-12 and folate levels.
    • infection workup, including blood cultures for anaerobic and aerobic organisms.
    • complete fever workup include the following:
      • Urinalysis
      • Urine culture and sensitivity
      • Culture of wound or catheter discharge
      • Stool for Clostridium difficile
      • Skin biopsy, if new erythematous and tender skin lesions are present
    • Broad-spectrum antibiotics should be started within 1 hour of cultures.
  • Procedures
    • bone marrow aspiration and obtain a biopsy
  • Medical Care
    • Discontinue drugs if they are suspected.
    • Corticosteroid therapy could be effective in immune-mediated neutropenia.
    • Correct nutritional deficiency (cobalamin or folic acid deficiency) if detected.
  • Treat the fever as an infection, as follows:
    • Third-generation cephalosporins (eg, ceftazidime, cefepime) or imipenem-cilastatin and meropenem can be used as a single agent.
    • Gentamicin or another aminoglycoside should be added if the neutropenic patient's condition is unstable or the individual appears septic.
    • Beta-lactam antibiotics (eg, ticarcillin, piperacillin) are usually used in combination with a third-generation cephalosporin or an aminoglycoside.
    • Vancomycin should be added if methicillin-resistant Staphylococcus aureus or Corynebacterium species is suspected.
    • If the neutropenic patient's fever does not respond within 4-5 days or if the fever recurs with the administration of broad-spectrum antibiotics after an initial afebrile interval
      • consider adding empiric antifungal coverage with amphotericin B (preferably lipid formulation)
      • a broad-spectrum azole (eg, voriconazole)
      • an echinocandin (eg, caspofungin).
    • Fever in patients with low-risk neutropenia can be treated on an outpatient basis with oral antibiotics.
  • Myeloid growth factors
    • granulocyte colony-stimulating factors (GCSFs)
    • granulocyte-macrophage colony-stimulating factor (GM-CSFs)
      • may shorten the duration of neutropenia in patients who have undergone chemotherapy.
  • Neutrophil (granulocyte) transfusion
    • some clinical usefulness in treating neonatal sepsis.
    • Cyclic neutropenia patients .
    • Congenital neutropenia patients.
    • Important supportive measures
      • Careful handwashing
      • Meticulous care of indwelling catheters
  • Surgical Care
    • In individuals with neutropenia and Felty syndrome who have recurrent life-threatening bacterial infections, splenectomy is the treatment of choice.
    • Indwelling central venous catheters should be removed in febrile neutropenic patients if septic thromboembolism is suspected. Other indications for catheter removal include the following:
      • Corynebacterium jeikeium infection
      • Infection with Candida species
      • Polymicrobial infection
      • Persistent fevers
      • Pocket-space abscess
      • Tunnel infections
  • Thank You…