Febrile neutropenia resident survival guide: Difference between revisions
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{{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Obtain a detailed history:'''<br> | {{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Obtain a detailed history:'''<br> | ||
❑ History of | ❑ History of any symptom of infections and inflammation of | ||
:❑ Skin and soft-tissues | :❑ Skin and soft-tissues | ||
:❑ Respiratory system | :❑ Respiratory system | ||
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❑ History of prior documentation of infections or pathogen colonization<br></div>}} | ❑ History of prior documentation of infections or pathogen colonization<br></div>}} | ||
{{familytree | | | | | | | |!| | | | | | |}} | {{familytree | | | | | | | |!| | | | | | |}} | ||
{{familytree | | | | | | | C01 | | | | | |C01= | {{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br> | ||
❑ | ❑ Search for signs of infections at | ||
❑ Oropharynx (perioduntum) | :❑ Entry and exit sites of catheters in skin | ||
❑ Alimentary tract | :❑ Sites of previous procedures in skin (example: bone marrow aspiration site) | ||
:❑ Oropharynx (including perioduntum) | |||
❑ Perineum | :❑ Lungs | ||
:❑ Alimentary tract | |||
:❑ Perineum</div>}} | |||
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{{familytree | | | | | | | D01 | | | | | |D01= | {{familytree | | | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order laboratory tests (routine):'''<br> | ||
''' | ❑ [[CBC]] with | ||
❑ [[CBC]]<br> | :❑ Differential leukocyte count | ||
❑ [[ | :❑ Platelet count<br> | ||
❑ [[ | ❑ [[BMP]] <br> | ||
❑ [[ | ❑ [[AST]]<br> | ||
❑ [[ALT]]<br> | |||
❑ [[Total bilirubin]]<br> | |||
❑ Blood cultures (at least 2 sets) | |||
:❑ When central catheter is present: One set from each lumen of an existing central catheter and another set from a peripheral vein site<br>'''or'''<br> | |||
:❑ When central catheter is absent: Two sets from separate venipunctures<br> | |||
❑ Urinalysis | |||
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'''Order additional tests (not routine and order when clinically indicated):'''<br> | |||
❑ Urine culture (Clinical indication: Urinary tract infection, urinary catheter in place, or abnormal findings on urinalysis)<br> | |||
❑ Chest X-ray (Clinical indication: Respiratory tract infection)<br> | |||
❑ CT head (Clinical indication: CNS infection)<br> | |||
❑ CT sinuses (Clinical indication: Sinus infection)<br> | |||
❑ CT abdomen (Clinical indication: Infection of abdominal organs)<br> | |||
❑ CT pelvis (Clinical indication: Infection of pelvic organs)<br> | |||
❑ CT pelvis (Clinical indication: Infection of pelvic organs)<br> | |||
❑ Stool for [[clostridium difficile]] toxin assay (Clinical indication: Diarrhea)<br> | |||
❑ Stool for bacterial pathogen cultures or for ova and parasite (Clinical indication: Diarrhea following a history of recent travel)<br> | |||
❑ CSF analysis and culture (Clinical indication: Meningitis)<br> | |||
❑ Skin aspiration or biopsy for cytological testing, gram staining, and culture (Clinical indication: Skin infection)<br> | |||
❑ Sputum analysis (Clinical indication: Productive cough)<br> | |||
❑ Bronchoalveolar lavage and analysis (Clinical indication: Infiltrations on chest imaging with an uncertain etiology)<br> | |||
❑ Nasal wash or bronchoalveolar lavage and assays for viral detection (Clinical indication: Respiratory infection during an outbreak or during winter)<br> | |||
---- | ---- | ||
'''Labs weekly during the course of antibiotics'''<br> | '''Labs weekly during the course of antibiotics'''<br> | ||
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---- | ---- | ||
'''Cultures:'''<br> | '''Cultures:'''<br> | ||
❑ Blood culture (repeat every day for two days) | ❑ Blood culture (repeat every day for two days)</div>}} | ||
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{{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} | {{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} |
Revision as of 01:50, 5 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Synonyms and keywords:
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
Characterize the symptoms: Symptom suggestive of neutropenic fever:
with
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Consider the diagnosis of neutropenic fever POTENTIALLY LIFE THREATENING | |||||||||||||||||||||||||||||
Obtain a detailed history: ❑ History of any symptom of infections and inflammation of
❑ History of any co-morbid conditions
❑ History of any recent exposure to infections | |||||||||||||||||||||||||||||
Examine the patient: ❑ Search for signs of infections at
| |||||||||||||||||||||||||||||
Order laboratory tests (routine): ❑ CBC with
❑ BMP
❑ Urinalysis Order additional tests (not routine and order when clinically indicated): Labs weekly during the course of antibiotics Cultures: | |||||||||||||||||||||||||||||
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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