Febrile neutropenia resident survival guide: Difference between revisions
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{{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Obtain a detailed history (an assessment of risk for complications of severe infections):'''<br> | {{familytree | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Obtain a detailed history (an assessment of risk for complications of severe infections):'''<br> | ||
❑ | ❑ Infections and inflammation of | ||
:❑ Skin and soft-tissues: | :❑ Skin and soft-tissues: | ||
::❑ [[Erythema]] | ::❑ [[Erythema]] | ||
::❑ Intravenous catheter site pain and/or swelling | ::❑ Intravenous catheter site [[pain]] and/or [[swelling]] | ||
::❑ Nodules | ::❑ [[Papule|Nodules]] | ||
::❑ [[Rash]] | ::❑ [[Rash]] | ||
::❑ [[Swelling]] | ::❑ [[Swelling]] | ||
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::❑ [[Altered mental status]] | ::❑ [[Altered mental status]] | ||
::❑ Behavioral or personality change | ::❑ Behavioral or personality change | ||
::❑ Clumsiness and unsteady gait | ::❑ [[Clumsiness]] and [[unsteady gait]] | ||
::❑ Decreased levels of consciousness | ::❑ Decreased levels of consciousness | ||
::❑ Delirium | ::❑ [[Delirium]] | ||
::❑ Headache | ::❑ [[Headache]] | ||
::❑ Irritability | ::❑ [[Irritability]] | ||
::❑ Lethargy | ::❑ [[Lethargy]] | ||
::❑ Neck stiffness | ::❑ [[Neck stiffness]] | ||
::❑ Phonophobia | ::❑ [[Phonophobia]] | ||
::❑ Photophobia | ::❑ [[Photophobia]] | ||
::❑ Seizures | ::❑ [[Seizures]] | ||
::❑ Vomiting | ::❑ [[Vomiting]] | ||
:❑ Oral cavity and oropharynx: | :❑ Oral cavity and oropharynx: | ||
::❑ Dental pain | ::❑ [[Dental pain]] | ||
::❑ Mouth ulcers | ::❑ [[Mouth ulcers]] | ||
::❑ Neck pain | ::❑ [[Neck pain]] | ||
:❑ Lungs (pneumonia): | :❑ Lungs ([[pneumonia]]): | ||
::❑ Dyspnea | ::❑ [[Dyspnea]] | ||
::❑ Fever (high grade) with sweating, chills, and rigor | ::❑ [[Fever]] (high grade) with [[sweating]], [[chills]], and [[rigor]] | ||
::❑ Pleuritic chest pain | ::❑ [[Pleuritic chest pain]] | ||
::❑ Productive cough (greenish or yellow sputum) | ::❑ Productive [[cough]] (greenish or yellow sputum) | ||
::❑ Rapid and shallow breathing | ::❑ Rapid and shallow breathing | ||
:❑ Abdomen (neutropenic enterocolitis or clostridium difficile colitis): | :❑ Abdomen ([[neutropenic enterocolitis]] or [[Clostridium difficile history and symptoms|clostridium difficile colitis]]): | ||
::❑ Diarrhea | ::❑ [[Diarrhea]] | ||
::❑ Crampy lower abdominal pain | ::❑ Crampy lower abdominal pain | ||
::❑ Fever with chills | ::❑ Fever with chills | ||
::❑ Nausea | ::❑ [[Nausea]] | ||
::❑ Abdominal distension | ::❑ [[Abdominal distension]] | ||
:❑ Urinary tract (urinary tract infection): | :❑ Urinary tract ([[urinary tract infection]]): | ||
::❑ Back, flank or groin pain | ::❑ Back, flank or groin pain | ||
::❑ Cloudy and foul-smelling urine | ::❑ Cloudy and foul-smelling urine | ||
::❑ Dysuria | ::❑ [[Dysuria]] | ||
::❑ Extreme fatigue | ::❑ [[Extreme fatigue]] | ||
::❑ Frequent urination | ::❑ [[Frequent urination]] | ||
::❑ Hematuria | ::❑ [[Hematuria]] | ||
::❑ Night sweats | ::❑ [[Night sweats]] | ||
::❑ Nocturia | ::❑ [[Nocturia]] | ||
::❑ Pain in the midline suprapubic region | ::❑ Pain in the midline suprapubic region | ||
::❑ Shaking chills and high spiking fever | ::❑ [[Rigor|Shaking chills]] and [[Fever|high spiking fever]] | ||
::❑ Vomiting<br> | ::❑ [[Vomiting]]<br> | ||
❑ History of any co-morbid conditions | ❑ History of any co-morbid conditions: | ||
:❑ Diabetes mellitus | :❑ [[Diabetes mellitus]] | ||
:❑ Chronic obstructive lung disease<br> | :❑ [[Chronic obstructive lung disease]]<br> | ||
❑ | ❑ Any recent exposure to infections<br> | ||
❑ | ❑ Any current antibiotic prophylaxis<br> | ||
❑ | ❑ Non infectious causes of fever | ||
❑ | :❑ [[Blood transfusions]] | ||
❑ | :❑ [[Pancreatic cancer|Uncontrolled cancer]]<br> | ||
❑ Any recent surgical procedures<br> | |||
❑ Any prior documentation of infections or pathogen colonization</div>}} | |||
{{familytree | | | | | | | |!| | | | | | |}} | {{familytree | | | | | | | |!| | | | | | |}} | ||
{{familytree | | | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient (an assessment of risk for complications of severe infections):'''<br> | {{familytree | | | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient (an assessment of risk for complications of severe infections):'''<br> | ||
❑ | ❑ [[Dehydration]]<br> | ||
❑ Vital signs: | ❑ Vital signs: | ||
::❑ Blood pressure: Look for hypotension (<90/50 mm Hg) | ::❑ Blood pressure: Look for [[hypotension]] (<90/50 mm Hg) | ||
::❑ Pulse rate: Look for tachycardia (> | ::❑ Pulse rate: Look for [[tachycardia]] (>100 beats/min) | ||
::❑ Respiratory rate: Look for tachypnea (>20 breaths/min) | ::❑ Respiratory rate: Look for [[tachypnea]] (>20 breaths/min) | ||
::❑ Oxygen saturation: Look for decreased oxygen saturation (<90%) | ::❑ Oxygen saturation: Look for [[decreased oxygen saturation]] (<90%) | ||
::❑ Temperature: Look for a single oral temperature ≥38.3° C (101° F) or a temperature ≥38° C (100.4° F) sustained for over one hour<br> | ::❑ Temperature: Look for a single oral temperature ≥38.3° C (101° F) or a temperature ≥38° C (100.4° F) sustained for over one hour<br> | ||
❑ | ❑ Signs of infections and inflammation at: | ||
:❑ Skin and soft-tissues: | :❑ Skin and soft-tissues: | ||
::❑ Cellulitis | ::❑ [[Cellulitis]] | ||
::❑ Ecthyma gangrenosum | ::❑ [[Ecthyma gangrenosum]] | ||
::❑ Erythema | ::❑ [[Erythema]] | ||
::❑ Erythema multiforme | ::❑ [[Erythema multiforme]] | ||
::❑ Erythema, swelling and/or tenderness at sites of previous procedures in skin (example: bone marrow aspiration site) | ::❑ [[Erythema]], [[swelling]] and/or [[tenderness]] at sites of previous procedures in skin (example: bone marrow aspiration site) | ||
::❑ Furuncles | ::❑ [[Furuncles]] | ||
::❑ Intravenous catheter site erythema and/or tenderness | ::❑ Intravenous catheter site [[erythema]] and/or [[tenderness]] | ||
::❑ Mucositis | ::❑ [[Mucositis]] | ||
::❑ Nodules | ::❑ [[Papule|Nodules]] | ||
::❑ Paronychia | ::❑ [[Paronychia]] | ||
::❑ Perianal fissures | ::❑ [[Anal fissure|Perianal fissures]] | ||
::❑ Pilonidal disease | ::❑ [[Pilonidal cyst|Pilonidal disease]] | ||
::❑ Rash | ::❑ [[Rash]] | ||
::❑ Skin lesions with a necrotic center | ::❑ Skin lesions with a necrotic center | ||
::❑ Ulcers | ::❑ [[Ulcers]] | ||
::❑ Vesicles | ::❑ [[Vesicles]] | ||
:❑ Central nervous system (meningitis and encephalitis): | :❑ Central nervous system ([[meningitis]] and [[encephalitis]]): | ||
::❑ Altered sensorium | ::❑ [[Altered mental status|Altered sensorium]] | ||
::❑ Brudzinski's sign | ::❑ [[Brudzinski's sign]] | ||
::❑ Kernig's sign | ::❑ [[Kernig's sign]] | ||
::❑ Nuchal rigidity | ::❑ [[Nuchal rigidity]] | ||
::❑ Personality changes | ::❑ Personality changes | ||
:❑ Oral cavity and oropharynx: | :❑ Oral cavity and oropharynx: | ||
::❑ Dental cellulitis | ::❑ Dental cellulitis | ||
::❑ Peritonsillar cellulitis | ::❑ Peritonsillar cellulitis | ||
::❑ Mouth ulcers | ::❑ [[Mouth ulcers]] | ||
:❑ Lungs ( | :❑ Lungs ([[pneumonia]]): | ||
::❑ Bronchial breath sounds | ::❑ Bronchial breath sounds | ||
::❑ Crackles | ::❑ [[Crackles]] | ||
::❑ Decreased breath sounds | ::❑ Decreased breath sounds | ||
::❑ Dullness on percussion | ::❑ Dullness on percussion | ||
::❑ Increased tactile fremitus | ::❑ [[Tactile fremitus|Increased tactile fremitus]] | ||
::❑ Increased volume of whispered (vocal fremitus) | ::❑ Increased volume of whispered ([[vocal fremitus]]) | ||
::❑ Rales | ::❑ [[Rales]] | ||
::❑ Rhonchi | ::❑ [[Rhonchi]] | ||
:❑ Abdomen (neutropenic enterocolitis or clostridium difficile colitis): | :❑ Abdomen ([[neutropenic enterocolitis]] or [[Clostridium difficile history and symptoms|clostridium difficile colitis]]): | ||
::❑ Abdominal distension | ::❑ [[Abdominal distension]] | ||
::❑ Abdominal tenderness | ::❑ Abdominal tenderness | ||
:❑ Urinary tract (urinary tract infection): | :❑ Urinary tract ([[urinary tract infection]]): | ||
::❑ Back or flank tenderness | ::❑ Back or flank tenderness | ||
::❑ Discomfort or pain at the urethral meatus | ::❑ Discomfort or pain at the urethral meatus | ||
::❑ Suprapubic tenderness | ::❑ Suprapubic tenderness | ||
:❑ Perineum: | :❑ Perineum: | ||
::❑ Erythema | ::❑ [[Erythema]] | ||
::❑ Tender hemorrhoids | ::❑ [[Hemorrhoids|Tender hemorrhoids]] | ||
::❑ Tenderness on palpation | ::❑ Tenderness on palpation | ||
'''Don't do digital rectal examination and rectal temperature recording (increased risk of traumatizing the fragile mucosa and introducing infections)'''</div>}} | '''Don't do digital rectal examination and rectal temperature recording (increased risk of traumatizing the fragile mucosa and introducing infections)'''</div>}} | ||
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❑ [[AST]]<br> | ❑ [[AST]]<br> | ||
❑ [[ALT]]<br> | ❑ [[ALT]]<br> | ||
❑ [[Total bilirubin]]<br> | ❑ [[Bilirubin|Total bilirubin]]<br> | ||
❑ Blood cultures (at least 2 sets) | ❑ Blood cultures (at least 2 sets) | ||
<table class="wikitable"> | <table class="wikitable"> |
Revision as of 18:05, 13 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, hot and low, F and N, a hot leuk
Overview
Febrile neutropenia 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 Febrile Neutropenia
Characterize the clinical and laboratory findings: ❑ Fever in cancer patients who are on chemotherapy
with | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider the diagnosis of febrile neutropenia POTENTIALLY LIFE THREATENING | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Obtain a detailed history (an assessment of risk for complications of severe infections): ❑ Infections and inflammation of
❑ History of any co-morbid conditions: ❑ Any recent exposure to infections ❑ Any recent surgical procedures | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient (an assessment of risk for complications of severe infections): ❑ Dehydration
❑ Signs of infections and inflammation 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 Febrile Neutropenia 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 Febrile Neutropenia 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 Febrile Neutropenia
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
|month=
ignored (help)