Febrile neutropenia resident survival guide: Difference between revisions
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{{SK}} Febrile neutropenia | {{SK}} Febrile neutropenia | ||
== | ==Overview== | ||
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/mm<sup>3</sup> or an [[ANC]] that is expected to become less than 500 cells/mm<sup>3</sup> over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm<sup>3</sup>. 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 [[infection]]s similarly to patients with low ANC.<ref name="Freifeld-2011">{{Cite journal | last1 = Freifeld | first1 = AG. | last2 = Bow | first2 = EJ. | last3 = Sepkowitz | first3 = KA. | last4 = Boeckh | first4 = MJ. | last5 = Ito | first5 = JI. | last6 = Mullen | first6 = CA. | last7 = Raad | first7 = II. | last8 = Rolston | first8 = KV. | last9 = Young | first9 = JA. | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. | journal = Clin Infect Dis | volume = 52 | issue = 4 | pages = e56-93 | month = Feb | year = 2011 | doi = 10.1093/cid/cir073 | PMID = 21258094 }}</ref> | 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/mm<sup>3</sup> or an [[ANC]] that is expected to become less than 500 cells/mm<sup>3</sup> over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm<sup>3</sup>. 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 [[infection]]s similarly to patients with low ANC.<ref name="Freifeld-2011">{{Cite journal | last1 = Freifeld | first1 = AG. | last2 = Bow | first2 = EJ. | last3 = Sepkowitz | first3 = KA. | last4 = Boeckh | first4 = MJ. | last5 = Ito | first5 = JI. | last6 = Mullen | first6 = CA. | last7 = Raad | first7 = II. | last8 = Rolston | first8 = KV. | last9 = Young | first9 = JA. | title = Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. | journal = Clin Infect Dis | volume = 52 | issue = 4 | pages = e56-93 | month = Feb | year = 2011 | doi = 10.1093/cid/cir073 | PMID = 21258094 }}</ref> | ||
Revision as of 14:50, 12 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
Overview
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 Day 1 Management
Low risk patients | |||||||||||||||||||||||||||||||||||||||||||||||||
Unexplained fever after day 1 | Clinically or microbiologically documented infection during day 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
❑ Persistent or recurrent fever and/or ❑ Clinically unstable | ❑ Responding to initial empirical therapy and/or ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site:
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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
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Modify antibiotics according to culture results and/or infection site:
| Responding | Not responding | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Continue antibiotics
and
| ❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection ❑ Consider culturing, biopsy, or draining sites of worsening infection ❑ Consider reviewing 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 Day 1 Management
High risk patients | |||||||||||||||||||||||||||||||||||||||||
Unexplained fever after day 1 | Clinically or microbiologically documented infection during day 1 | ||||||||||||||||||||||||||||||||||||||||
❑ Persistent or recurrent fever and/or ❑ Clinically stable | ❑ Responding to initial empirical therapy and/or ❑ Cultures negative | Modify antibiotics according to culture results and/or infection site:
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❑ Assess for infection sites ❑ Include CT of the chest and sinuses to assess for invasive fungal infection | Continue antibiotics until ANC >500 cells/mm3 and rising | ||||||||||||||||||||||||||||||||||||||||
❑ No changes in empirical antibiotics ❑ Consider continuing the empirical antibiotic therapy until ANC >500 cells/mm3 and rising ❑ Consider modifying the empirical antibiotic coverage based on the clinical or microbiologic evidence of infections (including anti-fungal agents) ❑ Consider starting fluoroquinolone prophylaxis for the remaining duration of neutropenia if afebrile for 4-5 days
| Recurrent fever during persistent neutropenia | ||||||||||||||||||||||||||||||||||||||||
Responding | Not responding | ||||||||||||||||||||||||||||||||||||||||
❑ Continue antibiotics
and
| ❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection ❑ Consider culturing, biopsy, or draining sites of worsening infection ❑ Consider reviewing 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 With Neutropenic Fever
High risk patients with prolonged (>4 days) fever | |||||||||||||||||||||||||||||||||||||||
❑ Daily review of systems ❑ Daily physical examination ❑ Blood cultures-repeat on limited basis ❑ Cultures for any suspected sites of infection | |||||||||||||||||||||||||||||||||||||||
Unexplained fever after day 4: ❑ Clinically stable ❑ ANC rising (myeloid recovery imminent) | Unexplained fever after day 4: ❑ Clinically stable ❑ ANC not rising (myeloid recovery not imminent) ❑ Consider CT scan sinuses and lungs | Clinically or microbiologically documented infection during days 1-4: ❑ Clinically unstable ❑ Worsening symptoms and signs of infection | |||||||||||||||||||||||||||||||||||||
❑ Observe the patient ❑ No changes in the antimicrobial regimen unless signs of new infection ❑ Clinical | ❑ Receiving antiyeast (fluconazole) prophylaxis | ❑ Receiving antimold (aspergillosis, zygomycosis, fusariosis) prophylaxis | ❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection ❑ Consider culturing, biopsy, or draining sites of worsening infection ❑ Consider reviewing antibiotic coverage for adequacy of dosing and spectrum ❑ Consider adding empirical antifungal therapy ❑ Broaden antimicrobial coverage for hemodynamic instability | ||||||||||||||||||||||||||||||||||||
Preemptive antifungal management: Order: ❑ CT chest and sinuses
❑ Serial serum b-(1-3)-D glucan test for
❑ Serial serum galactomannan test for
Administer antifungal therapy if: Withhold antifungal therapy if: | Empirical antifungal therapy with anti-mold therapy: ❑ Echinocandin ❑ Voriconazole ❑ Amphotericin B preparation | Empirical antifungal therapy: ❑ Consider switch to a different class of mold active antifungal | |||||||||||||||||||||||||||||||||||||
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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