Febrile neutropenia resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | A01 | | | | | | | | |A01='''High risk patients with prolonged (>4 days) fever'''}} | {{familytree | | | | | | | | | A01 | | | | | | | | |A01='''High risk patients with prolonged (>4 days) fever'''}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | | |}} | {{familytree | | | | | | | | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">❑ Daily review of systems<br>❑ Daily physical examination<br>❑ Blood cultures | {{familytree | | | | | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">❑ Daily review of systems<br>❑ Daily physical examination<br>❑ Blood cultures (repeat on limited basis)<br>❑ Cultures for any suspected sites of infection</div>}} | ||
{{familytree | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.|}} | {{familytree | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.|}} | ||
{{familytree | B01 | | | | | | B02 | | | | | | B03 |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Unexplained fever after day 4:'''<BR>❑ Clinically stable<br>❑ ANC rising (myeloid recovery imminent)</div> |B02=<div style="float: left; text-align: left; line-height: 150% ">'''Unexplained fever after day 4:'''<BR>❑ Clinically stable<br>❑ ANC not rising (myeloid recovery not imminent)<br>❑ Consider CT scan sinuses and lungs</div>|B03=<div style="float: left; text-align: left; line-height: 150% ">'''Clinically or microbiologically documented infection during days 1-4:'''<BR>❑ Clinically unstable<BR>❑ Worsening symptoms and signs of infection</div>}} | {{familytree | B01 | | | | | | B02 | | | | | | B03 |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Unexplained fever after day 4:'''<BR>❑ Clinically stable<br>❑ ANC rising (myeloid recovery imminent)</div> |B02=<div style="float: left; text-align: left; line-height: 150% ">'''Unexplained fever after day 4:'''<BR>❑ Clinically stable<br>❑ ANC not rising (myeloid recovery not imminent)<br>❑ Consider CT scan sinuses and lungs</div>|B03=<div style="float: left; text-align: left; line-height: 150% ">'''Clinically or microbiologically documented infection during days 1-4:'''<BR>❑ Clinically unstable<BR>❑ Worsening symptoms and signs of infection</div>}} | ||
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❑ Microbiologic<br> | ❑ Microbiologic<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Radiological</div>|C02=<div style="float: left; text-align: left; line-height: 150% "> | ❑ Radiological</div>|C02=<div style="float: left; text-align: left; line-height: 150% ">'''Patients receiving antiyeast (candida) prophylaxis:'''<br> | ||
❑ Fluconazole<br> | |||
'''or'''<br> | |||
❑ Itraconazole<br> | |||
'''or'''<br> | |||
❑ Voriconazole<br> | |||
'''or'''<br> | |||
❑ Posaconazole<br> | |||
'''or'''<br> | |||
❑ Micafungin<br> | |||
'''or'''<br> | |||
❑ Caspofungin<br> | |||
---- | |||
'''For:'''<br> | |||
❑ Allogeneic hematopoietic stem cell transplantation<br> | |||
'''or'''<br> | |||
❑ Intensive remission-induction or salvage induction chemotherapy following acute leukemia</div>|C03=<div style="float: left; text-align: left; line-height: 150% ">'''Patients receiving antimold (aspergillosis, zygomycosis, fusariosis) prophylaxis:''' | |||
❑ Posaconazole<br> | |||
---- | |||
'''For:'''<br> | |||
❑ Intensive chemotherapy following acute myeloid leukemia or myelodysplastic syndrome with an age >13 years<br> | |||
'''or'''<br> | |||
❑ Prior invasive aspergillosis<br> | |||
'''or'''<br> | |||
❑ Anticipated prolonged neutropenic periods (>2 weeks)<br> | |||
'''or'''<br> | |||
❑ Prolonged period of neutropenia prior to hematopoietic stem cell transplantation</div>|C04=<div style="float: left; text-align: left; line-height: 150% ">❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection<br>❑ Consider culturing, biopsy, or draining sites of worsening infection<br>❑ Consider reviewing antibiotic coverage for adequacy of dosing and spectrum<br>❑ Consider adding empirical antifungal therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | |||
{{familytree | | | | |,|-|^|-|.| | | |!| | | |}} | {{familytree | | | | |,|-|^|-|.| | | |!| | | |}} | ||
{{familytree | | | | D01 | | D02 | | D03 | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Preemptive antifungal management:'''<br>'''Order:'''<br> | {{familytree | | | | D01 | | D02 | | D03 | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Preemptive antifungal management:'''<br>'''Order:'''<br> | ||
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:❑ Aspergillus species<br> | :❑ Aspergillus species<br> | ||
---- | ---- | ||
'''Administer antifungal therapy if:'''<br> | '''Administer appropriate antifungal therapy if:'''<br> | ||
❑ Clinically unstable<br> | ❑ Clinically unstable<br> | ||
'''and/or'''<br> | '''and/or'''<br> | ||
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❑ Positive serologic assay results for evidence of invasive fungal infection<br> | ❑ Positive serologic assay results for evidence of invasive fungal infection<br> | ||
'''and/or'''<br> | '''and/or'''<br> | ||
❑ Recovery of fungi (eg. | ❑ Recovery of fungi (eg. candida or aspergillus species) from any body site<br> | ||
---- | ---- | ||
'''Withhold antifungal therapy if:'''<br> | '''Withhold existing antifungal therapy if:'''<br> | ||
❑ Clinically stable<br> | ❑ Clinically stable<br> | ||
'''and/or'''<br> | '''and/or'''<br> | ||
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❑ Negative serologic assay results for evidence of invasive fungal infection<br> | ❑ Negative serologic assay results for evidence of invasive fungal infection<br> | ||
'''and/or'''<br> | '''and/or'''<br> | ||
❑ No fungi (eg. candida or aspergillus species) recovered from any body site</div>|D02=<div style="float: left; text-align: left; line-height: 150% "> | ❑ No fungi (eg. candida or aspergillus species) recovered from any body site</div>|D02=<div style="float: left; text-align: left; line-height: 150% ">'''Add antimold therapy to the empirical antiyeast therapy:'''<br>❑ Echinocandin<br>'''or'''<br>❑ Voriconazole<br>'''or'''<br>❑ Amphotericin B preparation</div>|D03=<div style="float: left; text-align: left; line-height: 150% ">'''Consider switching to a different class of antimold agent'''</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 18:12, 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: FN, febrile leukopenia, neutropenic fever, neutropenic fever syndrome, neutropenic sepsis
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 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:
| |||||||||||||||||||||||||||||||||||||||||||||||
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
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:
| |||||||||||||||||||||||||||||||||||||||
❑ 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 (antiyeast or antimold) 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 | Patients receiving antiyeast (candida) prophylaxis: ❑ Fluconazole For: | Patients receiving antimold (aspergillosis, zygomycosis, fusariosis) prophylaxis:
❑ Posaconazole For: | ❑ 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 appropriate antifungal therapy if: Withhold existing antifungal therapy if: | Add antimold therapy to the empirical antiyeast therapy: ❑ Echinocandin or ❑ Voriconazole or ❑ Amphotericin B preparation | Consider switching to a different class of antimold agent | |||||||||||||||||||||||||||||||||||||
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)