Differences between first and subsequent fevers during prolonged neutropenia.

Fever during neutropenia before engraftment was studied in 86 consecutively treated patients undergoing allogeneic bone marrow transplantation. Eighty-four of the 86 patients experienced 132 febrile episodes. Only 26% of the patients had one fever which resolved with antibiotics. The rest required modification of antimicrobial therapy because of refractory fever (32%) or recurrent fevers (42%). The 121 fevers which occurred during neutropenia were analyzed to determine differences between first and subsequent fevers (79 and 42 episodes, respectively). The frequency of sepsis (23%) and defervescence (64%) did not differ between first and subsequent fevers. Presumed localized infection (PLI) was identified in 75% of first fever but in only 28% of subsequent fevers (P = 0.000002). Of the PLI identified, oropharyngeal mucosal disease accounted for 68% during first fever but only 38% during subsequent fevers (P = 0.02). Although sepsis in first fever was more frequently associated with PLI than sepsis in subsequent fevers (61% versus 10%, P = 0.01), overall, patients with PLI had a lower frequency of sepsis than those without (17% versus 32%, P = 0.04). Gram-negative pathogens were uniformly gentamicin sensitive in sepsis during first fever but were mostly gentamicin-resistant in sepsis during subsequent fevers (P = 0.01).