Febrile neutropenia resident survival guide: Difference between revisions
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==Definition== | ==Definition== | ||
Neutropenic [[fever]] is defined as one oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) for over one hour. [[Neutropenia]] is defined as an [[absolute neutrophil count]] (ANC) <500 cells/mm<sup>3</sup> or an [[ANC]] that is expected to become less than 500 cells/mm<sup>3</sup> over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm<sup>3</sup>. Patients with functional neutropenia have a qualitative abnormality of [[neutrophil]] functions despite a normal or elevated [[ANC]], as seen in hematological malignancy, and are at increased risk of [[infection]]s similarly to patients with low ANC. | Neutropenic [[fever]] is defined as one oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) for over one hour. [[Neutropenia]] is defined as an [[absolute neutrophil count]] (ANC) <500 cells/mm<sup>3</sup> or an [[ANC]] that is expected to become less than 500 cells/mm<sup>3</sup> over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm<sup>3</sup>. Patients with functional neutropenia have a qualitative abnormality of [[neutrophil]] functions despite a normal or elevated [[ANC]], as seen in hematological malignancy, and are at increased risk of [[infection]]s similarly to patients with low ANC.<ref name="Freifeld-2011">{{Cite journal | last1 = Freifeld | first1 = AG. | last2 = Bow | first2 = EJ. | last3 = Sepkowitz | first3 = KA. | last4 = Boeckh | first4 = MJ. | last5 = Ito | first5 = JI. | last6 = Mullen | first6 = CA. | last7 = Raad | first7 = II. | last8 = Rolston | first8 = KV. | last9 = Young | first9 = JA. | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. | journal = Clin Infect Dis | volume = 52 | issue = 4 | pages = e56-93 | month = Feb | year = 2011 | doi = 10.1093/cid/cir073 | PMID = 21258094 }}</ref> | ||
==Causes== | ==Causes== |
Revision as of 19:08, 4 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Definition
Neutropenic fever is defined as one oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) for over one hour. Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells/mm3 or an ANC that is expected to become less than 500 cells/mm3 over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm3. Patients with functional neutropenia have a qualitative abnormality of neutrophil functions despite a normal or elevated ANC, as seen in hematological malignancy, and are at increased risk of infections similarly to patients with low ANC.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Management
Initial Management
Confirm fever and neutropenia: ❑ Single oral temperature ≥38.3°c (101°F), OR | |||||||||||||||||||||||||||||
Obtain a detailed history: ❑ New site specific onset | |||||||||||||||||||||||||||||
Examine the patient: ❑ Site of previous procedures (entry and exit sites of catheters, bone marrow aspiration site) | |||||||||||||||||||||||||||||
Order lab tests and cultures: Labs every 3 days during the course of antibiotics: Labs weekly during the course of antibiotics Cultures: Additional tests (not routine) | |||||||||||||||||||||||||||||
DO A RISK ASSESSMENT | |||||||||||||||||||||||||||||
LOW RISK ❑ MASCC score* ≥21 ❑ Expected brief neutropenia (≤ 7 days) ❑ Clinically stable patient ❑ No comorbidities | HIGH RISK ❑ MASCC score* <21, OR | ||||||||||||||||||||||||||||
Outpatient oral antibiotics (Urgent) ❑ Ability to tolerate oral medications | Inpatient IV antibiotics (Urgent) ❑ Inability to tolerate oral medications | Inpatient IV antibiotics (Urgent) | |||||||||||||||||||||||||||
Administer oral antibiotics: ❑ ciprofloxacin + amoxicillin/clavulanate Observe and discharge: | Administer IV monotherapy with an antipseudomonal: ❑ Cefepime, OR ❑ Piperacillin/tazobactam, OR ❑ Carbapenem | ||||||||||||||||||||||||||||
Modify antibiotics if necessary: Add vancomycin if: Cover for organisms in case of previous infection, colonization, high endemicity: | |||||||||||||||||||||||||||||
Management 2 to 4 Days After Initiation of Antibiotic Treatment
Do's
- Modify the antibiotic regimens depending on the clinical picture and the epidemiology of infections in the area and the hospital where the patient is being treated at.
Don'ts
- Don't measure the temperature of the patient in the axillary area because it is not as specific as if it was taken orally.
- Don't measure the temperature of the patient rectally to avoid contaminating the skin and soft tissues of the rectal area.
References
- ↑ Freifeld, AG.; Bow, EJ.; Sepkowitz, KA.; Boeckh, MJ.; Ito, JI.; Mullen, CA.; Raad, II.; Rolston, KV.; Young, JA. (2011). "Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america". Clin Infect Dis. 52 (4): e56–93. doi:10.1093/cid/cir073. PMID 21258094. Unknown parameter
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ignored (help)