Febrile neutropenia resident survival guide: Difference between revisions
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{{CMG}}; {{AE}} {{Rim}} | {{CMG}}; {{AE}} {{Rim}} | ||
{{SK}} | {{SK}} Febrile neutropenia | ||
==Definition== | ==Definition== | ||
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{{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> | {{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"> | <table class="wikitable"> | ||
<tr class="v-firstrow"><th> | <tr class="v-firstrow"><th>Culture results and/or infection site</th><th>Modified regimen</th></tr> | ||
<tr><td>❑ Gram-negative bacteremia</td><td>❑ Administer a combination of | <tr><td>❑ Gram-negative bacteremia</td><td>❑ Administer a combination of | ||
<tr><td>❑ Gram-positive bacteremia or skin and soft-tissue infections </td><td>❑ Administer | :❑ Beta-lactam<br>'''or'''<br> | ||
:❑ Carbapenem<br> | |||
'''plus'''<br> | |||
:❑ Aminoglycosides<br>'''or'''<br> | |||
:❑ Fluoroquinolones<br> | |||
'''and'''<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<br>'''or'''<br> | |||
:❑ Linezolid<br>'''or'''<br> | |||
:❑ Daptomycin<br> | |||
'''and'''<br> | |||
❑ Adjust regimen based on susceptibility of pathogen</td></tr> | |||
<tr><td>❑ Pneumonia</td><td>❑ Administer a combination of | |||
:❑ Beta-lactam<br>'''or'''<br> | |||
:❑ Carbapenem<br> | |||
'''plus'''<br> | |||
:❑ Aminoglycosides<br>'''or'''<br> | |||
:❑ Antipseudomonal fluoroquinolones<br> | |||
'''and'''<br> | |||
❑ If MRSA suspected add | |||
:❑ Vancomycin<br>'''or'''<br> | |||
:❑ Linezolid <br> | |||
'''and'''<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>❑ HSV or candida esophagitis</td><td>❑ Administer acyclovir and/or fluconazole</td></tr> | ||
<tr><td>❑ Neutropenic enterocolitis</td><td>❑ Adminsiter<br> | <tr><td>❑ Neutropenic enterocolitis</td><td>❑ Adminsiter<br> | ||
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{{familytree | | |!| | | | | |,|-|^|-|.| | |}} | {{familytree | | |!| | | | | |,|-|^|-|.| | |}} | ||
{{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> | {{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 | <table class="wikitable"> | ||
<tr class="v-firstrow"><th>Culture results and/or infection site</th><th>Modified regimen</th></tr> | |||
<tr><td>❑ Drug-resistant gram-negative bacteria<br> | |||
❑ Drug-resistant gram-positive bacteria | |||
❑ Drug-resistant anaerobes</td><td>❑ Change from initial cephalosporin to | |||
:❑ Imipenem<br>'''or'''<br> | :❑ Imipenem<br>'''or'''<br> | ||
:❑ Meropenem<br> | :❑ Meropenem<br> | ||
❑ | ❑ If initially on vancomycin add | ||
:❑ Aminoglycoside<br>'''or'''<br> | :❑ Aminoglycoside<br>'''or'''<br> | ||
:❑ Ciprofloxacin<br>'''or'''<br> | :❑ Ciprofloxacin<br>'''or'''<br> | ||
:❑ Aztreonam< | :❑ Aztreonam</td></tr> | ||
❑ | <tr><td>❑ Suspected systemic inflammatory response syndrome</td><td>❑ Add fluconazole</td></tr> | ||
<tr><td>❑ Clostridium difficile</td><td>❑ Add | |||
:❑ Oral vancomycin<br>'''or'''<br> | |||
:❑ Oral metronidazole</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>|F02=Responding|F03=Not responding}} | |||
{{familytree | | |!| |!| | | | | | | |!| | |}} | {{familytree | | |!| |!| | | | | | | |!| | |}} | ||
{{familytree | | | G01 | | | | | | | G02 | |G01=Continue antibiotics for 7-14 days as appropriate for documented infection | {{familytree | | | G01 | | | | | | | G02 | |G01=<div style="float: left; text-align: left; line-height: 150% "> | ||
❑ Continue antibiotics for 7-14 days as appropriate for documented infection<br> | |||
'''or'''<br> | |||
❑ Until ANC >500 cells/mm<sup>3</sup> and rising<br> | |||
'''and'''<br> | |||
❑ Consider resuming oral fluoroquinolone prophylaxis until marrow recovery in patients | |||
:❑ Who remain neutropenic after completion of appropriate treatment | |||
:❑ Who's signs and symptoms of a documented infection has resolved</div> |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=== | ===Days 2 to 4: Management of High Risk Patients With Neutropenic Fever After Initiation of Empirical Antibiotic Therapy=== |
Revision as of 02:22, 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: Febrile neutropenia
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 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:
| Responding | Not responding | |||||||||||||||||||||||||||||||||||||||
❑ Continue antibiotics for 7-14 days as appropriate for documented infection
| ❑ 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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