Febrile neutropenia resident survival guide: Difference between revisions
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❑ 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 | | | |!| I02 | | I03 | | |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Consider continuing with inpatient IV antibiotics:'''<br> | {{familytree | | | |!| I02 | | I03 | | |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Consider continuing with inpatient IV broad-spectrum 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> | ||
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❑ Focused imaging studies</div>}} | ❑ Focused imaging studies</div>}} | ||
{{familytree | | | |!| |!| | | |!| | | | | | | |}} | {{familytree | | | |!| |!| | | |!| | | | | | | |}} | ||
{{familytree | | | | K01 | | | K02 | | | | | | |K01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider discharge with outpatient oral antibiotics:'''<br> | {{familytree | | | | K01 | | | K02 | | | | | | |K01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider discharge with outpatient oral broad-spectrum 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> | ||
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:❑ Focused imaging studies<br> | :❑ 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 for IV broad-spectrum antibiotics in case of | ||
:❑ Persisting fever | :❑ Persisting fever | ||
:❑ Recurrent fever | :❑ Recurrent fever | ||
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{{familytree | | | | B01 | | | | B02 | | | |B01=Unexplained fever|B02=Documented infection}} | {{familytree | | | | B01 | | | | B02 | | | |B01=Unexplained fever|B02=Documented infection}} | ||
{{familytree | | |,|-|^|-|.| | | |!| | | | |}} | {{familytree | | |,|-|^|-|.| | | |!| | | | |}} | ||
{{familytree | | C01 | | C02 | | C03 | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Persistent fever<br>❑ Clinically unstable</div>|C02=<div style="float: left; text-align: left; line-height: 150% ">❑ | {{familytree | | C01 | | C02 | | C03 | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Persistent or recurrent fever<br>❑ Clinically unstable</div>|C02=<div style="float: left; text-align: left; line-height: 150% ">❑ Responding to initial empirical therapy<br>❑ Cultures negative</div>|C03=Modify antibiotics according to culture results and/or infection site}} | ||
{{familytree | | |!| | | |!| | | |!| | | | |}} | {{familytree | | |!| | | |!| | | |!| | | | |}} | ||
{{familytree | | D01 | | D02 | | |!| | | | |D01=Hospitalize if outpatient for broad-spectrum IV antibiotics|D02=Continue oral or IV antibiotics until ANC > | {{familytree | | D01 | | D02 | | |!| | | | |D01=Hospitalize if outpatient for broad-spectrum IV antibiotics|D02=<div style="float: left; text-align: left; line-height: 150% ">❑ Continue the initial oral or IV broad-spectrum antibiotics until | ||
:❑ ANC is >500 cells/mm<sup>3</sup> and rising<br> | |||
❑ Consider discharging patients on IV broad-spectrum antibiotics with outpatient oral broad-spectrum antibiotics | |||
:❑ Ability to tolerate oral medications | |||
:❑ Availabilty of telephone, transportation to hospital, caregiver | |||
:❑ Fulminant infections are excluded | |||
:❑ Patient is clinically stable | |||
:❑ Patient and physician decision<br> | |||
❑ Monitor the patients on outpatient broad-spectrum antibiotics 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><br> | |||
❑ Consider re-admission of patients on outpatient broad-spectrum antibiotics for IV broad-spectrum antibiotics in case of | |||
:❑ Persisting fever | |||
:❑ Recurrent fever | |||
:❑ New signs of infection | |||
:❑ Decreasing neutrophil counts</div>}} | |||
{{familytree | | |!| | | | | | | |!| | | | |}} | {{familytree | | |!| | | | | | | |!| | | | |}} | ||
{{familytree | | |!| | | | | |,|-|^|-|.| | |}} | {{familytree | | |!| | | | | |,|-|^|-|.| | |}} |
Revision as of 18:39, 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 broad-spectrum 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 broad-spectrum 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
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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
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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 or recurrent fever ❑ Clinically unstable | ❑ Responding to initial empirical therapy ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site | |||||||||||||||||||||||||||||
Hospitalize if outpatient for broad-spectrum IV antibiotics | ❑ Continue the initial oral or IV broad-spectrum antibiotics until
❑ Consider discharging patients on IV broad-spectrum antibiotics with outpatient oral broad-spectrum antibiotics
❑ Monitor the patients on outpatient broad-spectrum antibiotics for recovery, adverse drug effects, secondary infections and development of drug-resistance with
❑ Consider re-admission of patients on outpatient broad-spectrum antibiotics for IV broad-spectrum antibiotics in case of
| ||||||||||||||||||||||||||||||
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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