Febrile neutropenia resident survival guide: Difference between revisions
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==Management== | ==Management== | ||
===Day 1: Initial Management=== | ===Day 1: Initial Management of Patients With Neutropenic Fever=== | ||
{{familytree/start |summary=Neutropenic fever}} | {{familytree/start |summary=Neutropenic fever}} | ||
{{familytree | | | | | | | A01 | | | | | |A01= <div style="float: left; text-align: left; width: 30em; padding:1em;">'''Characterize the symptoms:'''<br> | {{familytree | | | | | | | A01 | | | | | |A01= <div style="float: left; text-align: left; width: 30em; padding:1em;">'''Characterize the symptoms:'''<br> | ||
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<tr><td>❑ Age <60 years</td><td>❑ 2</td></tr> | <tr><td>❑ Age <60 years</td><td>❑ 2</td></tr> | ||
</table></div>}} | </table></div>}} | ||
{{familytree | | | | |, | {{familytree | | | | | |,|-|^|-|.| | | | |}} | ||
{{familytree | | | | G01 | {{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<br> | ||
---- | ---- | ||
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---- | ---- | ||
'''Afebrile neutropenic patients with new signs or symptoms suggestive of infection'''</div>}} | '''Afebrile neutropenic patients with new signs or symptoms suggestive of infection'''</div>}} | ||
{{familytree | | | | |!| | | | | | {{familytree | | | | | |!| | | |!| | | | |}} | ||
{{familytree | | | | H01 | | | | {{familytree | | | | | H01 | | H02 | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Administer oral or IV empirical broad-spectrum antibiotic therapy (URGENT):'''<BR> | ||
❑ [[Ciprofloxacin]] + [[Amoxicillin-clavulanate]]<BR> | ❑ [[Ciprofloxacin]] + [[Amoxicillin-clavulanate]]<BR> | ||
❑ In clinic or hospital setting | ❑ In clinic or hospital setting | ||
❑ Observe for 4-24 hours after drug administration</div>|H02='''Hospitalize the patient'''}} | ❑ Observe for 4-24 hours after drug administration</div>|H02='''Hospitalize the patient'''}} | ||
{{familytree | | | | | {{familytree | | | |,|-|(| | | |!| | | | | |}} | ||
{{familytree | {{familytree | | | |!| I02 | | I03 | | |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Consider continuing with inpatient IV antibiotics:'''<br> | ||
❑ Inability to tolerate oral medications<br> | ❑ Inability to tolerate oral medications<br> | ||
❑ Unavailabilty of telephone, transportation to hospital, caregiver<br> | ❑ Unavailabilty of telephone, transportation to hospital, caregiver<br> | ||
❑ Identified infections requiring IV antibiotics<br> | ❑ Identified infections requiring IV antibiotics<br> | ||
❑ Patient is clinically unstable<br> | ❑ Patient is clinically unstable<br> | ||
❑ Patient and physician decision</div>| | ❑ Patient and physician decision</div>|I03=<div style="float: left; text-align: left; line-height: 150% ">'''Administer IV empirical antipseudomonal antibiotic monotherapy (URGENT):'''<br> | ||
❑ [[Cefepime]]<br> | ❑ [[Cefepime]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
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'''or'''<br> | '''or'''<br> | ||
❑ [[Imipenem-cilastatin]]</div>}} | ❑ [[Imipenem-cilastatin]]</div>}} | ||
{{familytree | | | | |!| | | {{familytree | | | |!| | |!| |!| | | | | |}} | ||
{{familytree | | | | | | {{familytree | | | |!| |,| J01 |.| | | | | |J01=<div style="float: left; text-align: left; line-height: 150% ">'''Inpatient monitoring:'''<br> | ||
Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with<br> | |||
❑ Daily review of systems<br> | |||
❑ Daily physical examination<br> | |||
❑ Cultures of specimens from suspicious sites<br> | |||
❑ Focused imaging studies</div>}} | |||
{{familytree | | | |!| |!| | | |!| | | | | | | |}} | |||
{{familytree | | | | K01 | | | K02 | | | | | | |K01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider discharge with outpatient oral antibiotics:'''<br> | |||
❑ Ability to tolerate oral medications<br> | ❑ Ability to tolerate oral medications<br> | ||
❑ Availabilty of telephone, transportation to hospital, caregiver<br> | ❑ Availabilty of telephone, transportation to hospital, caregiver<br> | ||
❑ Fulminant infections are excluded<br> | ❑ Fulminant infections are excluded<br> | ||
❑ Patient is clinically stable<br> | ❑ Patient is clinically stable<br> | ||
❑ Patient and physician decision</div>| | ❑ Patient and physician decision</div>|K02= <div style="float: left; text-align: left; line-height: 150% ">'''Add [[vancomycin]] to the initial empirical antibiotic monotherapy for:'''<br> | ||
❑ Suspected Catheter related infection<br>❑ Suspected skin and soft tissue infection<br>❑ Suspected [[pneumonia]]<br>❑ Hemodynamic instability<br>❑ Positive gram-positive bacterial blood culture (that is available before the final identification and susceptibility test)<br>❑ Colonization with [[MRSA]], [[VRE]], or penicillin-resistant streptococcus pneumoniae<br>❑ Severe mucositis (following fluoroquinolone prophylaxis and use of ceftazidime as empirical therapy) | ❑ Suspected Catheter related infection<br>❑ Suspected skin and soft tissue infection<br>❑ Suspected [[pneumonia]]<br>❑ Hemodynamic instability<br>❑ Positive gram-positive bacterial blood culture (that is available before the final identification and susceptibility test)<br>❑ Colonization with [[MRSA]], [[VRE]], or penicillin-resistant streptococcus pneumoniae<br>❑ Severe mucositis (following fluoroquinolone prophylaxis and use of ceftazidime as empirical therapy) | ||
---- | ---- | ||
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<tr><td>❑ [[KPCs]]</td><td>❑ [[Polymyxin-colistin]]<br>'''or'''<br>❑ [[Tigecycline]]</td></tr> | <tr><td>❑ [[KPCs]]</td><td>❑ [[Polymyxin-colistin]]<br>'''or'''<br>❑ [[Tigecycline]]</td></tr> | ||
</table></div>}} | </table></div>}} | ||
{{familytree | | | | | | | {{familytree | | | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | {{familytree | | | | L01 | | | | | | | | | | | |L01=<div style="float: left; text-align: left; line-height: 150% ">'''Outpatient monitoring:'''<br> | ||
❑ | ❑ Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with<br> | ||
:❑ Daily review of systems | |||
:❑ Daily physical examination | |||
:❑ Cultures of specimens from suspicious sites | |||
:❑ Focused imaging studies<br> | |||
❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care<br> | ❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care<br> | ||
❑ Consider re-admission in case of | ❑ Consider re-admission in case of | ||
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{{familytree/end}} | {{familytree/end}} | ||
===Days 2 to 4: Management After Initiation of Empirical Antibiotic Therapy=== | ===Days 2 to 4: Management of Low Risk Patients With Neutropenic Fever After Initiation of Empirical Antibiotic Therapy=== | ||
{{familytree/start |summary=Neutropenic fever}} | {{familytree/start |summary=Neutropenic fever}} | ||
{{familytree | | | | | | | A01 | | | | | | |A01='''Low risk patients'''}} | {{familytree | | | | | | | A01 | | | | | | |A01='''Low risk patients'''}} | ||
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{{familytree | | | G01 | | | | | | | G02 | |G01=Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 10<sup>9</sup> cells/L and rising|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ Examine and re-image (CT, MRI) for new or worsening sites of infection<br>❑ Culture/biopsy/drain sites of worsening infection<br>❑ Review antibiotic coverage for adequacy of dosing and spectrum<br>❑ Consider adding empirical antifungal therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | {{familytree | | | G01 | | | | | | | G02 | |G01=Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 10<sup>9</sup> cells/L and rising|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ Examine and re-image (CT, MRI) for new or worsening sites of infection<br>❑ Culture/biopsy/drain sites of worsening infection<br>❑ Review antibiotic coverage for adequacy of dosing and spectrum<br>❑ Consider adding empirical antifungal therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Days 2 to 4: Management of High Risk Patients With Neutropenic Fever After Initiation of Empirical Antibiotic Therapy=== | |||
{{familytree/start |summary=Neutropenic fever}} | {{familytree/start |summary=Neutropenic fever}} | ||
{{familytree | | | | | | | A01 | | | | | | |A01='''High risk patients'''}} | {{familytree | | | | | | | A01 | | | | | | |A01='''High risk patients'''}} | ||
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{{familytree | | | | | | | | G01 | | G02 | |G01=Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 10<sup>9</sup> cells/L and rising|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ Examine and re-image (CT, MRI) for new or worsening sites of infection<br>❑ Culture/biopsy/drain sites of worsening infection<br>❑ Review antibiotic coverage for adequacy of dosing and spectrum<br>❑ Consider adding empirical antifungal therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | {{familytree | | | | | | | | G01 | | G02 | |G01=Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 10<sup>9</sup> cells/L and rising|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ Examine and re-image (CT, MRI) for new or worsening sites of infection<br>❑ Culture/biopsy/drain sites of worsening infection<br>❑ Review antibiotic coverage for adequacy of dosing and spectrum<br>❑ Consider adding empirical antifungal therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===After Day 4: Management of High Risk Patients Neutropenic Fever=== | |||
==Do's== | ==Do's== |
Revision as of 17:37, 10 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
Day 1: Initial Management of Patients With Neutropenic Fever
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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Administer oral or IV empirical broad-spectrum antibiotic therapy (URGENT): ❑ Ciprofloxacin + Amoxicillin-clavulanate | Hospitalize the patient | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider continuing with inpatient IV antibiotics: ❑ Inability to tolerate oral medications | Administer IV empirical antipseudomonal antibiotic monotherapy (URGENT): ❑ Cefepime | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Inpatient monitoring: Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider discharge with outpatient oral antibiotics: ❑ Ability to tolerate oral medications | Add vancomycin to the initial empirical antibiotic monotherapy for: ❑ Suspected Catheter related infection Consider modifying the initial empirical antibiotic monotherapy for:
or
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Outpatient monitoring: ❑ Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with
❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Days 2 to 4: Management of Low Risk Patients With Neutropenic Fever After Initiation of Empirical Antibiotic Therapy
Low risk patients | |||||||||||||||||||||||||||||||
Unexplained fever | Documented infection | ||||||||||||||||||||||||||||||
❑ Persistent fever ❑ Clinically unstable | ❑ Defervesed ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site | |||||||||||||||||||||||||||||
Hospitalize if outpatient for broad-spectrum IV antibiotics | Continue oral or IV antibiotics until ANC >0.5 x 109 cells/L and rising | ||||||||||||||||||||||||||||||
Modify antibiotics according to culture results and/or infection site | Responding | Not responding | |||||||||||||||||||||||||||||
Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 109 cells/L and rising | ❑ Examine and re-image (CT, MRI) for new or worsening sites of infection ❑ Culture/biopsy/drain sites of worsening infection ❑ Review antibiotic coverage for adequacy of dosing and spectrum ❑ Consider adding empirical antifungal therapy ❑ Broaden antimicrobial coverage for hemodynamic instability | ||||||||||||||||||||||||||||||
Days 2 to 4: Management of High Risk Patients With Neutropenic Fever After Initiation of Empirical Antibiotic Therapy
High risk patients | |||||||||||||||||||||||||||||||
Unexplained fever | Documented infection | ||||||||||||||||||||||||||||||
❑ Persistent fever ❑ Clinically stable | ❑ Defervesed ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site | |||||||||||||||||||||||||||||
❑ No changes in empirical antibiotics ❑ Assess for infection sites | Continue antibiotics until ANC >0.5 x 109 cells/L and rising | ||||||||||||||||||||||||||||||
Recurrent fever during persistent neutropenia | |||||||||||||||||||||||||||||||
Responding | Not responding | ||||||||||||||||||||||||||||||
Continue antibiotics for 7-14 days as appropriate for documented infection, or longer, i.e. until ANC >0.5 x 109 cells/L and rising | ❑ Examine and re-image (CT, MRI) for new or worsening sites of infection ❑ Culture/biopsy/drain sites of worsening infection ❑ Review antibiotic coverage for adequacy of dosing and spectrum ❑ Consider adding empirical antifungal therapy ❑ Broaden antimicrobial coverage for hemodynamic instability | ||||||||||||||||||||||||||||||
After Day 4: Management of High Risk Patients Neutropenic Fever
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)