Febrile neutropenia resident survival guide: Difference between revisions
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❑ Presence of comorbidities (neurological changes, gastrointestinal symptoms, underlying chronic lung disease, intravascular catheter infection, hemodynamic instability, hepatic insufficiency, or renal insufficiency)<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>}} | '''Patients who do not strictly fulfill the criteria for being at low risk'''<br> | ||
---- | |||
'''Afebrile neutropenic patients with new signs or symptoms suggestive of infection'''</div>}} | |||
{{familytree | | |,|-|^|-|.| | | |!| | | |}} | {{familytree | | |,|-|^|-|.| | | |!| | | |}} | ||
{{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> | ||
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'''Observe and discharge:'''<br> | '''Observe and discharge:'''<br> | ||
❑ Observe for 4 hours following the initial dose of antibiotics and discharge for outpatient treatment after making sure the patient is stable and tolerating the treatment</div> | ❑ Observe for 4 hours following the initial dose of antibiotics and discharge for outpatient treatment after making sure the patient is stable and tolerating the treatment</div> | ||
|I02= <div style="float: left; text-align: left; line-height: 150% ">''' | |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Administer IV empirical antibiotics (antipseudomonal monotherapy) (URGENT):'''<br> | ||
❑ [[Cefepime]]<br> | |||
'''or'''<br> | |||
❑ [[Piperacillin-tazobactam]]<br> | |||
'''or'''<br> | |||
❑ [[Meropenem]]<br> | |||
'''or'''<br> | |||
❑ [[Imipenem-cilastatin]]</div>}} | |||
{{familytree | | | | | | | | | | |!| | | |}} | {{familytree | | | | | | | | | | |!| | | |}} | ||
{{familytree | | | | | | | | | | J02 | | |J02= <div style="float: left; text-align: left; line-height: 150% ">''' | {{familytree | | | | | | | | | | J02 | | |J02= <div style="float: left; text-align: left; line-height: 150% ">'''Add other antibiotics for management of complications:'''<br> | ||
'''Add [[vancomycin]] if:'''<br> | '''Add [[vancomycin]] if:'''<br> | ||
❑ | ❑ Catheter related infection suspected<br>❑ Skin and soft tissue infection suspected<br>❑ [[Pneumonia]] suspected<br>❑ Hemodynamic instability is present<br> | ||
---- | ---- | ||
''' | '''Consider modifying the initial empirical antibiotic therapy for:'''<br> | ||
❑ [[MRSA]] | ❑ Suspected antimicrobial resistance: | ||
❑ [[VRE]] | :❑ Patient is unstable | ||
❑ [[ | :❑ Patient's positive blood culture is suspicious for a resistant bacteria | ||
❑ [[ | :❑ Patient has/had treatment in a hospital with high rates of endemicity | ||
</div>}} | :❑ Patient had previous history of any infection or colonization with an organism<br> | ||
'''or'''<br> | |||
❑ Proven antimicrobial resistance where the blood cultures are positive for resistant bacteria <br> | |||
<table class="wikitable"> | |||
<tr class="v-firstrow"><th>For</th><th>Add</th></tr> | |||
<tr><td>❑ [[MRSA]]</td><td>❑ [[Vancomycin]]<br>'''or'''<br>❑ [[Linezolid]]<br>'''or'''<br>❑ [[Daptomycin]]</td></tr> | |||
<tr><td>❑ [[VRE]]</td><td>❑ [[Linezolid]]<br>'''or'''<br>❑ [[Daptomycin]]</td></tr> | |||
<tr><td>❑ [[ESBLs]]</td><td>❑ [[Carbapenem]]</td></tr> | |||
<tr><td>❑ [[KPCs]]</td><td>❑ [[Polymyxin-colistin]]<br>'''or'''<br>❑ [[Tigecycline]]</td></tr> | |||
</table></div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 17:42, 6 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 using MASCC risk Index: (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 Afebrile neutropenic patients with new signs or symptoms suggestive of infection | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Outpatient oral antibiotics (Urgent) ❑ Ability to tolerate oral medications | Inpatient IV antibiotics (Urgent) ❑ Inability to tolerate oral medications | Hospitalize the patient | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Administer oral antibiotics: ❑ ciprofloxacin + amoxicillin/clavulanate Observe and discharge: | Administer IV empirical antibiotics (antipseudomonal monotherapy) (URGENT): ❑ Cefepime | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Add other antibiotics for management of complications: Add vancomycin if: Consider modifying the initial empirical antibiotic therapy for:
or
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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)