Ward 86 Management Recommendations
updated April 2016
Contributors: Mark A. Jacobson, MD
Annie Luetkemeyer, MD
Neutropenia occurs frequently in HIV disease and may be attributable to AIDS-related processes infiltrating the bone marrow, drug toxicity, hypersplenism, antineutrophil antibodies, or the effects of uncontrolled HIV infection itself.
The clinical implications of neutropenia are related to a patient's bone marrow reserve (ie, the marrow's capacity to produce more circulating neutrophils).
In neutropenia that is drug-induced or caused by a marrow-infiltrative process, there is little or absent marrow reserve. Hence, risk of serious infection is high when neutropenia is severe (eg, absolute neutrophil count [ANC] of <500 cells/µL, especially when <100 cells/µL).
If neutropenia is caused by hypersplenism or antineutrophil antibodies, the marrow reserve is usually normal. In such cases, risk of serious infection is lower, even with severe neutropenia.
Two useful clinical clues regarding marrow reserve are:
Patients with abscesses clearly have adequate marrow reserve.
Gingivitis and mucosal ulcers are signs of inadequate marrow reserve.
- Among HIV-infected patients, there is an increased risk of serious bacterial infection associated with having an ANC of <500 cells/µL. Higher counts do not merit interventions such as administering growth factor therapy or discontinuing myelosuppressive medications because absolute neutrophil counts of >500 cells/µL are not associated with a significantly increased risk of hospitalization for serious bacterial infection.(1)
Patients who have an ANC of <500 cells/µL that is attributable to ganciclovir, TMP-SMX, amphotericin, or zidovudine treatment should ideally have the culprit medication stopped and replaced with a less myelosuppressive alternative. However, if the myelosuppressive medication must be continued, adjuvant granulocyte-colony stimulating factor (G-CSF) can be given to address the neutropenia.(2) For most such patients, G-CSF 1 vial SQ 1-3 times/week will sufficiently raise the nadir ANC (at end of longest interval between injections) to >500 cells/µL.
There is no evidence of benefit to support administering growth factor therapy to HIV patients with severe neutropenia when it is caused by an underlying disease process, such as a marrow infiltrative process, rather than by myelosuppressive medication.
- Jacobson MA, Liu RC, Davies D, et al. Human immunodeficiency virus disease-related neutropenia and the risk of hospitalization for bacterial infection. Arch Intern Med. 1997 Sep 8;157(16):1825-31.
- Kuritzkes DR, Parenti D, Ward DJ, et al. Filgrastim prevents severe neutropenia and reduces infective morbidity in patients with advanced HIV infection: results of a randomized, multicenter, controlled trial. G-CSF 930101 Study Group. AIDS. 1998 Jan 1;12(1):65-74.