Febrile neutropenia resident survival guide: Difference between revisions
No edit summary |
No edit summary |
||
Line 196: | Line 196: | ||
{{familytree | | | | | | | A01 | | | | | | |A01='''Low risk patients'''}} | {{familytree | | | | | | | A01 | | | | | | |A01='''Low risk patients'''}} | ||
{{familytree | | | | |,|-|-|^|-|-|.| | | | |}} | {{familytree | | | | |,|-|-|^|-|-|.| | | | |}} | ||
{{familytree | | | | B01 | | | | B02 | | | |B01=Unexplained fever|B02= | {{familytree | | | | B01 | | | | B02 | | | |B01=Unexplained fever after day 1|B02=Clinically or microbiologically documented infection during day 1}} | ||
{{familytree | | |,|-|^|-|.| | | |!| | | | |}} | {{familytree | | |,|-|^|-|.| | | |!| | | | |}} | ||
{{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 | | 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=<div style="float: left; text-align: left; line-height: 150% ">'''Modify antibiotics according to culture results and/or infection site:'''<br> | ||
<table class="wikitable"> | |||
<tr class="v-firstrow"><th>For</th><th>Modified regimen</th></tr> | |||
<tr><td>❑ Gram-negative bacteremia</td><td>❑ Administer a combination of beta-lactam or carbapenem plus aminoglycosides or fluoroquinolones<br>❑ Switch to a monotherapy with a beta-lactam agent once the susceptibilities are known</td></tr> | |||
<tr><td>❑ Gram-positive bacteremia or skin and soft-tissue infections </td><td>❑ Administer vancomycin or linezolid or daptomycin<br>❑ Adjust regimen based on susceptibility of pathogen</td></tr><tr><td>❑ Pneumonia</td><td>❑ Administer a combination of beta-lactam or carbapenem plus aminoglycosides or antipseudomonal fluoroquinolone<br>❑ Add vancomycin or linezolid if MRSA suspected<br>❑ Adjust regimen based on susceptibility of pathogens and clinical progress</td></tr> | |||
<tr><td>❑ HSV or candida esophagitis</td><td>❑ Administer acyclovir and/or fluconazole</td></tr> | |||
<tr><td>❑ Neutropenic enterocolitis</td><td>❑ Adminsiter<br> | |||
:❑ Monotherapy: Piperacillin-tazobactam or carbapenem<br>'''or'''<br> | |||
:❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole</td></tr> | |||
</table></div>}} | |||
{{familytree | | |!| | | |!| | | |!| | | | |}} | {{familytree | | |!| | | |!| | | |!| | | | |}} | ||
{{familytree | | D01 | | D02 | | |!| | | | |D01=Hospitalize | {{familytree | | D01 | | D02 | | |!| | | | |D01=<div style="float: left; text-align: left; line-height: 150% "> | ||
'''Inpatient management:'''<br> | |||
❑ Consider discharging patients | ❑ Hospitalize the patients who are on outpatient broad-spectrum antibiotics<br> | ||
❑ Continue the patients who are on inpatient IV broad-spectrum antibiotics with inpatient management<br> | |||
---- | |||
'''Order:'''<br> | |||
❑ A new set of blood cultures<br> | |||
❑ Stool sample for [[C. difficile]] antigen and toxin assay (if diarrhea is present)<br> | |||
❑ Abdominal CT (if abdominal pain and diarrhea is present)<br> | |||
❑ Other symptom related diagnostic tests<br> | |||
---- | |||
'''Consider noninfectious causess:'''<br> | |||
❑ Drug related fever<br> | |||
❑ Thrombophlebitis<br> | |||
❑ Underlying cancer<br> | |||
❑ Resorption of blood from a large hematoma</div>|D02=<div style="float: left; text-align: left; line-height: 150% ">'''Continue the initial oral or IV broad-spectrum antibiotics until:'''<br> | |||
❑ ANC is >500 cells/mm<sup>3</sup> and rising<br> | |||
---- | |||
'''Outpatient management:'''<br> | |||
❑ Consider discharging patients with oral broad-spectrum antibiotics | |||
:❑ Ability to tolerate oral medications | :❑ Ability to tolerate oral medications | ||
:❑ Availabilty of telephone, transportation to hospital, caregiver | :❑ Availabilty of telephone, transportation to hospital, caregiver | ||
Line 208: | Line 234: | ||
:❑ Patient is clinically stable | :❑ Patient is clinically stable | ||
:❑ Patient and physician decision<br> | :❑ Patient and physician decision<br> | ||
❑ Monitor the patients | ❑ Monitor the patients for recovery, adverse drug effects, secondary infections and development of drug-resistance with<br> | ||
:❑ Daily review of systems | :❑ Daily review of systems | ||
:❑ Daily physical examination | :❑ Daily physical examination | ||
:❑ Cultures of specimens from suspicious sites | :❑ Cultures of specimens from suspicious sites | ||
:❑ Focused imaging studies<br><br> | :❑ Focused imaging studies<br> | ||
❑ Consider re-admission of patients | ❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care<br> | ||
❑ Consider re-admission of patients in case of | |||
:❑ Persisting fever | :❑ Persisting fever | ||
:❑ Recurrent fever | :❑ Recurrent fever | ||
Line 220: | Line 247: | ||
{{familytree | | |!| | | | | | | |!| | | | |}} | {{familytree | | |!| | | | | | | |!| | | | |}} | ||
{{familytree | | |!| | | | | |,|-|^|-|.| | |}} | {{familytree | | |!| | | | | |,|-|^|-|.| | |}} | ||
{{familytree | | F01 |,|-|-| F02 | | F03 | |F01=Modify antibiotics according to culture results and/or infection site|F02=Responding|F03=Not responding}} | {{familytree | | F01 |,|-|-| F02 | | F03 | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Modify antibiotics according to culture results and/or infection site:'''<br> | ||
❑ Change from an initial cephalosporin to an anti-pseudomonal carbapenem | |||
:❑ Imipenem<br>'''or'''<br> | |||
:❑ Meropenem<br> | |||
❑ To vancomycin add | |||
:❑ Aminoglycoside<br>'''or'''<br> | |||
:❑ Ciprofloxacin<br>'''or'''<br> | |||
:❑ Aztreonam<br> | |||
❑ Add fluconazole if systemic inflammatory response syndrome is suspected </div>|F02=Responding|F03=Not responding}} | |||
{{familytree | | |!| |!| | | | | | | |!| | |}} | {{familytree | | |!| |!| | | | | | | |!| | |}} | ||
{{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>}} |
Revision as of 01:21, 11 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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Order laboratory tests (routine): ❑ CBC with
❑ BMP
❑ Urinalysis Order additional tests (not routine and order if clinically indicated):
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do a risk assessment using MASCC risk Index: (MANDATORY)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 after day 1 | Clinically or microbiologically documented infection during day 1 | ||||||||||||||||||||||||||||||||||||||||
❑ Persistent or recurrent fever ❑ Clinically unstable | ❑ Responding to initial empirical therapy ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site:
| |||||||||||||||||||||||||||||||||||||||
Inpatient management: Order: Consider noninfectious causess: | Continue the initial oral or IV broad-spectrum antibiotics until: ❑ ANC is >500 cells/mm3 and rising Outpatient management:
❑ Monitor the patients 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
| ||||||||||||||||||||||||||||||||||||||||
Modify antibiotics according to culture results and/or infection site: ❑ Change from an initial cephalosporin to an anti-pseudomonal carbapenem
❑ To vancomycin add
| 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
|month=
ignored (help)