Febrile neutropenia resident survival guide: Difference between revisions
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{{familytree | | | | | | | F01 | | | | | |F01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''[[Febrile neutropenia# Multinational Association for Supportive Care in Cancer (MASCC) Risk Index|Do a risk assessment:]]''' '''(MANDATORY)'''<br> | {{familytree | | | | | | | F01 | | | | | |F01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''[[Febrile neutropenia# Multinational Association for Supportive Care in Cancer (MASCC) Risk Index|Do a risk assessment:]]''' '''(MANDATORY)'''<br> | ||
<table class="wikitable"> | <table class="wikitable"> | ||
<tr class="v-firstrow"><th> | <tr class="v-firstrow"><th>Characteristic</th><th>Weight</th></tr> | ||
<tr><td>❑ No or mild symptoms in patients following an episode of febrile neutropenia</td><td>❑ 5</td></tr> | <tr><td>❑ No or mild symptoms in patients following an episode of febrile neutropenia</td><td>❑ 5</td></tr> | ||
<tr><td>❑ Absence of hypotension with a systolic blood pressure >90 mmHg</td><td>❑ 5</td></tr> | <tr><td>❑ Absence of hypotension with a systolic blood pressure >90 mmHg</td><td>❑ 5</td></tr> | ||
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{{familytree | | | | | {{familytree | | | | G01 | | | | G02 | | |G01= <div style="float: left; text-align: left; line-height: 150% ">'''Low risk patients:'''<br> | ||
| | ❑ MASCC score ≥21<br> | ||
❑ MASCC score <21 | ---- | ||
❑ Expected prolonged neutropenia (> 7 days) | '''or'''<br> | ||
❑ Presence of comorbidities </div>}} | ---- | ||
❑ Expected brief neutropenia (≤7 days)<br>'''and/or'''<br> | |||
❑ Clinically stable<br>'''and/or'''<br> | |||
❑ Absence of comorbidities (neurological changes, gastrointestinal symptoms, underlying chronic lung disease, intravascular catheter infection, hemodynamic instability, hepatic insufficiency, or renal insufficiency)</div>|G02=<div style="float: left; text-align: left; line-height: 150% ">'''High risk patients:'''<br> | |||
❑ MASCC score <21<BR> | |||
---- | |||
'''or'''<br> | |||
---- | |||
❑ Expected prolonged neutropenia (>7 days)<BR>'''and'''<br> | |||
❑ Profound neutropenia (ANC≤100 cells mm<sup>3</sup>)<br>'''and/or'''<br> | |||
❑ Clinically unstable (unbearable pain, altered mental status, or hypotension)<br>'''and/or'''<br> | |||
❑ Presence of comorbidities (neurological changes, gastrointestinal symptoms, underlying chronic lung disease, intravascular catheter infection, hemodynamic instability, hepatic insufficiency, or renal insufficiency)<br> | |||
---- | |||
'''Patients who do not strictly fulfill the criteria for being at low risk'''</div>}} | |||
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{{familytree | | H01 | | H02 | | H03 | | |H01= <div style="float: left; text-align: left; line-height: 150% ">'''Outpatient oral antibiotics (Urgent)'''<br> | {{familytree | | H01 | | H02 | | H03 | | |H01= <div style="float: left; text-align: left; line-height: 150% ">'''Outpatient oral antibiotics (Urgent)'''<br> |
Revision as of 20:42, 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)
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Low risk patients: ❑ MASCC score ≥21 or ❑ Expected brief neutropenia (≤7 days) | High risk patients: ❑ MASCC score <21 or ❑ Expected prolonged neutropenia (>7 days) Patients who do not strictly fulfill the criteria for being at low risk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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)