Febrile neutropenia resident survival guide: Difference between revisions
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❑ History of non infectious causes of fever (example: administration of blood products)<br> | ❑ History of non infectious causes of fever (example: administration of blood products)<br> | ||
❑ History of recent surgical procedures<br> | ❑ History of recent surgical procedures<br> | ||
❑ History of prior documentation of infections or pathogen colonization | ❑ History of prior documentation of infections or pathogen colonization</div>}} | ||
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{{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br> | {{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br> | ||
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'''Order additional tests (not routine and order when clinically indicated):'''<br> | '''Order additional tests (not routine and order when clinically indicated):'''<br> | ||
❑ Urine culture | <table class="wikitable"> | ||
❑ Chest X-ray | <tr class="v-firstrow"><th>Tests</th><th>Clinical indications</th></tr> | ||
❑ CT head | <tr><td>❑ Urine culture</td><td>❑ Urinary tract infection<br>❑ Urinary catheter in place<br>❑ Abnormal findings on urinalysis</td></tr> | ||
❑ CT sinuses | <tr><td>❑ Chest X-ray</td><td>❑ Respiratory tract infection</td></tr> | ||
❑ CT abdomen | <tr><td>❑ CT head</td><td>❑ CNS infection</td></tr> | ||
❑ CT pelvis | <tr><td>❑ CT sinuses</td><td>❑ Sinus infection</td></tr> | ||
❑ Stool for [[clostridium difficile]] toxin assay | <tr><td>❑ CT abdomen</td><td>❑ Infection of abdominal organs</td></tr> | ||
❑ Stool for bacterial pathogen cultures or for ova and parasite | <tr><td>❑ CT pelvis</td><td>❑ Infection of pelvic organs</td></tr> | ||
❑ CSF analysis and culture | <tr><td>❑ Stool for [[clostridium difficile]] toxin assay</td><td>❑ Diarrhea</td></tr> | ||
❑ Skin aspiration or biopsy for cytological testing, gram staining, and culture | <tr><td>❑ Stool for bacterial pathogen cultures or for ova and parasite</td><td>❑ Diarrhea following a history of recent travel</td></tr> | ||
❑ Sputum analysis | <tr><td>❑ CSF analysis and culture</td><td>❑ Meningitis</td></tr> | ||
❑ Bronchoalveolar lavage and analysis | <tr><td>❑ Skin aspiration or biopsy for cytological testing, gram staining, and culture</td><td>❑ Skin infection</td></tr> | ||
❑ Nasal wash or bronchoalveolar lavage and assays for viral detection | <tr><td>❑ Sputum analysis</td><td>❑ Productive cough</td></tr> | ||
<tr><td>❑ Bronchoalveolar lavage and analysis</td><td>❑ Infiltrations on chest imaging with an uncertain etiology</td></tr> | |||
<tr><td>❑ Nasal wash or bronchoalveolar lavage and assays for viral detection</td><td>❑ Respiratory infection during an outbreak or during winter</td></tr> | |||
</table></div>}} | |||
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{{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} | {{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} |
Revision as of 17:35, 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
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Order laboratory tests (routine): ❑ CBC with
❑ BMP
❑ Urinalysis Order additional tests (not routine and order when clinically indicated):
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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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