Management of Neutropenic Patients with Diarrhea

Diagnosis and Risk Stratification

Neutropenic patients with diarrhea and prior pelvic radiation should be categorized as having severe disease regardless of fever status, and require immediate stool testing for Clostridium difficile and empiric treatment with oral vancomycin or fidaxomicin while awaiting results, as recommended by the European Society for Medical Oncology 1, 2
The American Society of Clinical Oncology suggests that neutropenic patients cannot mount leukocytosis, and those with chemotherapy-associated bowel syndrome or prior radiation are at higher risk for complications and death 1, 2

The Infectious Diseases Society of America recommends starting oral vancomycin 125 mg four times daily OR fidaxomicin 200 mg twice daily immediately while awaiting C. difficile test results in high-risk patients, with a strength of evidence of I (high) 1, 2
The European Society for Medical Oncology suggests that prior pelvic radiation increases CDI risk and complicates differential diagnosis, and neutropenic patients with severe disease have 2-7% mortality from CDI 1, 2

The National Comprehensive Cancer Network recommends administering IV fluids for dehydration, and monitoring and replacing electrolytes (particularly potassium) daily, with a category 1 recommendation 3
The American Society of Clinical Oncology suggests encouraging 8-10 glasses of clear liquids daily (electrolyte solutions, broth) when tolerating oral intake, and eliminating lactose-containing products (chemotherapy can cause transient lactose intolerance) 3, 6

The European Society for Medical Oncology recommends considering temporary interruption of chemotherapy until diarrhea resolves and patient is clinically stable, with a level of evidence of III (moderate) 3
The American Society of Clinical Oncology suggests that chemotherapy-induced diarrhea is common (27-76% of neutropenic patients) but only 5-17% have infectious causes, and fluorouracil-based regimens and irinotecan carry highest diarrhea risk 6, 4, 5

The Infectious Diseases Society of America recommends continuing vancomycin or fidaxomicin for 10 days if CDI confirmed, with a strength of evidence of I (high) 1, 2
The European Society for Medical Oncology suggests obtaining early surgical evaluation if patient develops signs of toxic megacolon or perforation, severe abdominal pain with peritoneal signs, or clinical deterioration despite appropriate therapy, with a level of evidence of III (moderate) 1, 2, 5