Febrile neutropenia resident survival guide: Difference between revisions
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❑ History of prior documentation of infections or pathogen colonization</div>}} | ❑ History of prior documentation of infections or pathogen colonization</div>}} | ||
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{{familytree | | | | | | | | {{familytree | | | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br> | ||
❑ Search for signs of infections at | ❑ Search for signs of infections at | ||
:❑ Entry and exit sites of catheters in skin | :❑ Entry and exit sites of catheters in skin | ||
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:❑ Perineum</div>}} | :❑ Perineum</div>}} | ||
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{{familytree | | | | | | | | {{familytree | | | | | | | E01 | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order laboratory tests (routine):'''<br> | ||
❑ [[CBC]] with | ❑ [[CBC]] with | ||
:❑ Differential leukocyte count | :❑ Differential leukocyte count | ||
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❑ [[ALT]]<br> | ❑ [[ALT]]<br> | ||
❑ [[Total bilirubin]]<br> | ❑ [[Total bilirubin]]<br> | ||
❑ Blood cultures (at least 2 sets) | ❑ Blood cultures (at least 2 sets) | ||
<table class="wikitable"> | |||
<tr class="v-firstrow"><th>Central catheter</th><th>1<sup>st</sup> set</th><th>2<sup>nd</sup> set</th></tr> | |||
<tr><td>❑ Present</td><td>❑ From each lumen of existing central catheters</td><td>❑ From a peripheral vein site</td></tr> | |||
<tr><td>❑ Absent</td><td>❑ From one separate venipuncture</td><td>❑ From another separate venipuncture</td></tr> | |||
</table><br> | |||
❑ Urinalysis | ❑ Urinalysis | ||
---- | ---- | ||
'''Order additional tests (not routine and order | '''Order additional tests (not routine and order if clinically indicated):'''<br> | ||
<table class="wikitable"> | <table class="wikitable"> | ||
<tr class="v-firstrow"><th>Tests</th><th>Clinical indications</th></tr> | <tr class="v-firstrow"><th>Tests</th><th>Clinical indications</th></tr> | ||
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</table></div>}} | </table></div>}} | ||
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{{familytree | | | | | | | | {{familytree | | | | | | | F01 | | | | | |F01='''Do a risk assessment'''<br>'''(MANDATORY)'''}} | ||
{{familytree | | | | |,|-|-|^|-|-|.| | | |}} | {{familytree | | | | |,|-|-|^|-|-|.| | | |}} | ||
{{familytree | | | | F01 | | | | F02 | | |F01= <div style="float: left; text-align: left; line-height: 150% ">'''LOW RISK'''<br>❑ MASCC score* ≥21 <br>❑ Expected brief neutropenia (≤ 7 days) <br>❑ Clinically stable patient <br>❑ No comorbidities </div> | {{familytree | | | | F01 | | | | F02 | | |F01= <div style="float: left; text-align: left; line-height: 150% ">'''LOW RISK'''<br>❑ MASCC score* ≥21 <br>❑ Expected brief neutropenia (≤ 7 days) <br>❑ Clinically stable patient <br>❑ No comorbidities </div> |
Revision as of 18:00, 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 if clinically indicated):
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Do a risk assessment (MANDATORY) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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