Febrile neutropenia resident survival guide: Difference between revisions
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❑ [[CBC]] with | ❑ [[CBC]] with | ||
:❑ Differential leukocyte count | :❑ Differential leukocyte count | ||
:❑ Platelet count<br> | :❑ [[Platelet count]]<br> | ||
❑ [[BMP]] <br> | ❑ [[BMP]] <br> | ||
❑ [[AST]]<br> | ❑ [[AST]]<br> | ||
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<table class="wikitable"> | <table class="wikitable"> | ||
<tr class="v-firstrow"><th>Tests</th><th>Clinical indications</th></tr> | <tr class="v-firstrow"><th>Tests</th><th>Clinical indications</th></tr> | ||
<tr><td>❑ Urine culture</td><td>❑ Urinary tract infection<br>❑ Urinary catheter in place<br>❑ Abnormal findings on urinalysis</td></tr> | <tr><td>❑ Urine culture</td><td>❑ [[Urinary tract infection]]<br>❑ Urinary catheter in place<br>❑ Abnormal findings on urinalysis</td></tr> | ||
<tr><td>❑ Chest X-ray</td><td>❑ Respiratory tract infection</td></tr> | <tr><td>❑ Chest X-ray</td><td>❑ [[Respiratory tract infection]]</td></tr> | ||
<tr><td>❑ CT head</td><td>❑ CNS infection</td></tr> | <tr><td>❑ CT head</td><td>❑ [[CNS infection]]</td></tr> | ||
<tr><td>❑ CT sinuses</td><td>❑ Sinus infection</td></tr> | <tr><td>❑ CT sinuses</td><td>❑ [[Sinus infection]]</td></tr> | ||
<tr><td>❑ CT abdomen</td><td>❑ Infection of abdominal organs</td></tr> | <tr><td>❑ CT abdomen</td><td>❑ Infection of abdominal organs</td></tr> | ||
<tr><td>❑ CT pelvis</td><td>❑ Infection of pelvic organs</td></tr> | <tr><td>❑ CT pelvis</td><td>❑ Infection of pelvic organs</td></tr> | ||
<tr><td>❑ Stool for [[clostridium difficile]] toxin assay</td><td>❑ Diarrhea</td></tr> | <tr><td>❑ Stool for [[clostridium difficile]] toxin assay</td><td>❑ [[Diarrhea]]</td></tr> | ||
<tr><td>❑ Stool for bacterial pathogen cultures or for ova and parasite</td><td>❑ Diarrhea following a history of recent travel</td></tr> | <tr><td>❑ Stool for bacterial pathogen cultures or for ova and parasite</td><td>❑ [[Diarrhea]] following a history of recent travel</td></tr> | ||
<tr><td>❑ CSF analysis and culture</td><td>❑ Meningitis</td></tr> | <tr><td>❑ CSF analysis and culture</td><td>❑ [[Meningitis]]</td></tr> | ||
<tr><td>❑ Skin aspiration or biopsy for cytological testing, gram staining, and culture</td><td>❑ Skin infection</td></tr> | <tr><td>❑ Skin aspiration or biopsy for cytological testing, gram staining, and culture</td><td>❑ [[Skin infection]]</td></tr> | ||
<tr><td>❑ Sputum analysis</td><td>❑ Productive cough</td></tr> | <tr><td>❑ Sputum analysis</td><td>❑ Productive cough</td></tr> | ||
<tr><td>❑ Bronchoalveolar lavage and analysis</td><td>❑ Infiltrations on chest imaging with an uncertain etiology</td></tr> | <tr><td>❑ [[Bronchoalveolar lavage]] and analysis</td><td>❑ Infiltrations on chest imaging with an uncertain etiology</td></tr> | ||
<tr><td>❑ Nasal wash or bronchoalveolar lavage and assays for viral detection</td><td>❑ Respiratory infection during an outbreak or during winter</td></tr> | <tr><td>❑ Nasal wash or bronchoalveolar lavage and assays for viral detection</td><td>❑ Respiratory infection during an outbreak or during winter</td></tr> | ||
</table></div>}} | </table></div>}} | ||
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<tr class="v-firstrow"><th>Characteristic</th><th>Score</th></tr> | <tr class="v-firstrow"><th>Characteristic</th><th>Score</th></tr> | ||
<tr><td>❑ No or mild symptoms in patients following an episode of febrile neutropenia</td><td>❑ 5</td></tr> | <tr><td>❑ No or mild symptoms in patients following an episode of febrile neutropenia</td><td>❑ 5</td></tr> | ||
<tr><td>❑ Absence of hypotension with a systolic blood pressure >90 mmHg</td><td>❑ 5</td></tr> | <tr><td>❑ Absence of [[hypotension]] with a systolic blood pressure >90 mmHg</td><td>❑ 5</td></tr> | ||
<tr><td>❑ No chronic obstructive pulmonary disease (active chronic bronchitis, emphysema, decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or bronchodilators)</td><td>❑ 4</td></tr> | <tr><td>❑ No [[chronic obstructive pulmonary disease]] (active [[chronic bronchitis]], [[emphysema]], decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or [[bronchodilators]])</td><td>❑ 4</td></tr> | ||
<tr><td>❑ Solid tumor or hematologic malignancy with no previously demonstrated fungal infection or empirically treated suspected fungal infection</td><td>❑ 4</td></tr> | <tr><td>❑ Solid tumor or hematologic malignancy with no previously demonstrated fungal infection or empirically treated suspected fungal infection</td><td>❑ 4</td></tr> | ||
<tr><td>❑ Absence of dehydration that requires parenteral fluids</td><td>❑ 3</td></tr> | <tr><td>❑ Absence of dehydration that requires parenteral fluids</td><td>❑ 3</td></tr> | ||
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❑ [[Meropenem]]<br> | ❑ [[Meropenem]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ [[Imipenem | ❑ [[Imipenem cilastatin]]</div>}} | ||
{{familytree | | | |!| | |!| |!| | | | | |}} | {{familytree | | | |!| | |!| |!| | | | | |}} | ||
{{familytree | | | |!| |,| J01 |.| | | | | |J01=<div style="float: left; text-align: left; line-height: 150% ">'''Inpatient monitoring:'''<br> | {{familytree | | | |!| |,| J01 |.| | | | | |J01=<div style="float: left; text-align: left; line-height: 150% ">'''Inpatient monitoring:'''<br> | ||
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❑ Patient is clinically stable<br> | ❑ Patient is clinically stable<br> | ||
❑ Patient and physician decision</div>|K02= <div style="float: left; text-align: left; line-height: 150% ">'''Add [[vancomycin]] to the initial empirical antibiotic monotherapy for:'''<br> | ❑ Patient and physician decision</div>|K02= <div style="float: left; text-align: left; line-height: 150% ">'''Add [[vancomycin]] to the initial empirical antibiotic monotherapy for:'''<br> | ||
❑ Suspected Catheter related infection<br>❑ Suspected skin and soft tissue infection<br>❑ Suspected [[pneumonia]]<br>❑ Hemodynamic instability<br>❑ Positive gram-positive bacterial blood culture (that is available before the final identification and susceptibility test)<br>❑ Colonization with [[MRSA]], [[VRE]], or penicillin-resistant streptococcus pneumoniae<br>❑ Severe mucositis (following fluoroquinolone prophylaxis and use of ceftazidime as empirical therapy) | ❑ Suspected Catheter related infection<br>❑ Suspected skin and soft tissue infection<br>❑ Suspected [[pneumonia]]<br>❑ Hemodynamic instability<br>❑ Positive gram-positive bacterial blood culture (that is available before the final identification and susceptibility test)<br>❑ Colonization with [[MRSA]], [[VRE]], or penicillin-resistant streptococcus pneumoniae<br>❑ Severe mucositis (following [[fluoroquinolone]] prophylaxis and use of ceftazidime as empirical therapy) | ||
---- | ---- | ||
'''Consider modifying the initial empirical antibiotic monotherapy for:'''<br> | '''Consider modifying the initial empirical antibiotic monotherapy for:'''<br> | ||
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<tr class="v-firstrow"><th>Culture results and/or infection site</th><th>Modified regimen</th></tr> | <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 | ||
:❑ Beta-lactam<br>'''or'''<br> | :❑ [[Beta-lactam]]<br>'''or'''<br> | ||
:❑ Carbapenem<br> | :❑ [[Carbapenem]]<br> | ||
'''plus'''<br> | '''plus'''<br> | ||
:❑ Aminoglycosides<br>'''or'''<br> | :❑ [[Aminoglycosides]]<br>'''or'''<br> | ||
:❑ Fluoroquinolones<br> | :❑ [[Fluoroquinolones]]<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Switch to a monotherapy with a beta-lactam agent once the susceptibilities are known</td></tr> | ❑ 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 | <tr><td>❑ Gram-positive bacteremia or skin and soft-tissue infections </td><td>❑ Administer | ||
:❑ Vancomycin<br>'''or'''<br> | :❑ [[Vancomycin]]<br>'''or'''<br> | ||
:❑ Linezolid<br>'''or'''<br> | :❑ [[Linezolid]]<br>'''or'''<br> | ||
:❑ Daptomycin<br> | :❑ [[Daptomycin]]<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Adjust regimen based on susceptibility of pathogen</td></tr> | ❑ Adjust regimen based on susceptibility of pathogen</td></tr> | ||
<tr><td>❑ Pneumonia</td><td>❑ Administer a combination of | <tr><td>❑ [[Pneumonia]]</td><td>❑ Administer a combination of | ||
:❑ Beta-lactam<br>'''or'''<br> | :❑ [[Beta-lactam]]<br>'''or'''<br> | ||
:❑ Carbapenem<br> | :❑ [[Carbapenem]]<br> | ||
'''plus'''<br> | '''plus'''<br> | ||
:❑ Aminoglycosides<br>'''or'''<br> | :❑ [[Aminoglycosides]]<br>'''or'''<br> | ||
:❑ Antipseudomonal | :❑ Antipseudomonal [[fluoroquinolone]]s<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ If MRSA suspected add | ❑ If [[MRSA]] suspected add | ||
:❑ Vancomycin<br>'''or'''<br> | :❑ [[Vancomycin]]<br>'''or'''<br> | ||
:❑ Linezolid <br> | :❑ [[Linezolid]] <br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Adjust regimen based on susceptibility of pathogens and clinical progress</td></tr> | ❑ 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> | ||
:❑ Monotherapy: Piperacillin-tazobactam or carbapenem<br>'''or'''<br> | :❑ Monotherapy: [[Piperacillin-tazobactam]] or [[carbapenem]]<br>'''or'''<br> | ||
:❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole</td></tr> | :❑ Combination therapy: Anti-pseudomonal cephalosporin plus [[metronidazole]]</td></tr> | ||
</table></div>}} | </table></div>}} | ||
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'''Order:'''<br> | '''Order:'''<br> | ||
❑ A new set of blood cultures<br> | ❑ A new set of blood cultures<br> | ||
❑ Stool sample for [[ | ❑ Stool sample for [[clostridium difficile]] antigen and toxin assay (if diarrhea is present)<br> | ||
❑ Abdominal CT (if abdominal pain and diarrhea is present)<br> | ❑ Abdominal CT (if abdominal pain and diarrhea is present)<br> | ||
❑ Other symptom related diagnostic tests<br> | ❑ Other symptom related diagnostic tests<br> | ||
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❑ Drug-resistant gram-positive bacteria | ❑ Drug-resistant gram-positive bacteria | ||
❑ Drug-resistant anaerobes</td><td>❑ Change from initial cephalosporin to | ❑ 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 | ❑ If initially on [[vancomycin]] add | ||
:❑ Aminoglycoside<br>'''or'''<br> | :❑ [[Aminoglycoside]]<br>'''or'''<br> | ||
:❑ Ciprofloxacin<br>'''or'''<br> | :❑ [[Ciprofloxacin]]<br>'''or'''<br> | ||
:❑ Aztreonam</td></tr> | :❑ [[Aztreonam]]</td></tr> | ||
<tr><td>❑ Suspected systemic inflammatory response syndrome</td><td>❑ Add fluconazole</td></tr> | <tr><td>❑ Suspected [[systemic inflammatory response syndrome]]</td><td>❑ Add [[fluconazole]]</td></tr> | ||
<tr><td>❑ Clostridium difficile</td><td>❑ Add | <tr><td>❑ [[Clostridium difficile]]</td><td>❑ Add | ||
:❑ Oral vancomycin<br>'''or'''<br> | :❑ Oral [[vancomycin]]<br>'''or'''<br> | ||
:❑ Oral metronidazole</td></tr> | :❑ Oral [[metronidazole]]</td></tr> | ||
<tr><td>❑ Neutropenic enterocolitis</td><td>❑ Adminsiter<br> | <tr><td>❑ [[Neutropenic enterocolitis]]</td><td>❑ Adminsiter<br> | ||
:❑ Monotherapy: Piperacillin-tazobactam or carbapenem<br>'''or'''<br> | :❑ Monotherapy: [[Piperacillin-tazobactam]] or [[carbapenem]]<br>'''or'''<br> | ||
:❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole</td></tr> | :❑ Combination therapy: Anti-pseudomonal cephalosporin plus [[metronidazole]]</td></tr> | ||
</table></div>|F02=Responding|F03=Not responding}} | </table></div>|F02=Responding|F03=Not responding}} | ||
{{familytree | | | | |!| |!| | | | | | | |!| | | | |}} | {{familytree | | | | |!| |!| | | | | | | |!| | | | |}} | ||
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❑ Continue antibiotics | ❑ Continue antibiotics | ||
:❑ For 7-14 days as appropriate for documented infection<br>'''or'''<br> | :❑ For 7-14 days as appropriate for documented infection<br>'''or'''<br> | ||
:❑ Until ANC >500 cells/mm<sup>3</sup> and rising<br> | :❑ Until [[ANC]] >500 cells/mm<sup>3</sup> and rising<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Consider resuming oral fluoroquinolone prophylaxis until ANC >500 cells/mm<sup>3</sup> and rising in patients | ❑ Consider resuming oral [[fluoroquinolone]] prophylaxis until ANC >500 cells/mm<sup>3</sup> and rising in patients | ||
:❑ Who remain neutropenic after completion of appropriate treatment | :❑ 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% ">❑ 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>}} | :❑ Who's signs and symptoms of a documented infection has resolved</div> |G02=<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>}} | ||
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<tr class="v-firstrow"><th>Culture results and/or infection site</th><th>Modified regimen</th></tr> | <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 | ||
:❑ Beta-lactam<br>'''or'''<br> | :❑ [[Beta-lactam]]<br>'''or'''<br> | ||
:❑ Carbapenem<br> | :❑ [[Carbapenem]]<br> | ||
'''plus'''<br> | '''plus'''<br> | ||
:❑ Aminoglycosides<br>'''or'''<br> | :❑ [[Aminoglycosides]]<br>'''or'''<br> | ||
:❑ Fluoroquinolones<br> | :❑ [[Fluoroquinolones]]<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Switch to a monotherapy with a beta-lactam agent once the susceptibilities are known</td></tr> | ❑ 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 | <tr><td>❑ Gram-positive bacteremia or skin and soft-tissue infections </td><td>❑ Administer | ||
:❑ Vancomycin<br>'''or'''<br> | :❑ [[Vancomycin]]<br>'''or'''<br> | ||
:❑ Linezolid<br>'''or'''<br> | :❑ [[Linezolid]]<br>'''or'''<br> | ||
:❑ Daptomycin<br> | :❑ [[Daptomycin]]<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Adjust regimen based on susceptibility of pathogen</td></tr> | ❑ Adjust regimen based on susceptibility of pathogen</td></tr> | ||
<tr><td>❑ Pneumonia</td><td>❑ Administer a combination of | <tr><td>❑ [[Pneumonia]]</td><td>❑ Administer a combination of | ||
:❑ Beta-lactam<br>'''or'''<br> | :❑ [[Beta-lactam]]<br>'''or'''<br> | ||
:❑ Carbapenem<br> | :❑ [[Carbapenem]]<br> | ||
'''plus'''<br> | '''plus'''<br> | ||
:❑ Aminoglycosides<br>'''or'''<br> | :❑ [[Aminoglycosides]]<br>'''or'''<br> | ||
:❑ Antipseudomonal fluoroquinolones<br> | :❑ Antipseudomonal [[fluoroquinolones]]<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ If MRSA suspected add | ❑ If [[MRSA]] suspected add | ||
:❑ Vancomycin<br>'''or'''<br> | :❑ [[Vancomycin]]<br>'''or'''<br> | ||
:❑ Linezolid <br> | :❑ [[Linezolid]] <br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Adjust regimen based on susceptibility of pathogens and clinical progress</td></tr> | ❑ 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> | ||
:❑ Monotherapy: Piperacillin-tazobactam or carbapenem<br>'''or'''<br> | :❑ Monotherapy: [[Piperacillin-tazobactam]] or [[carbapenem]]<br>'''or'''<br> | ||
:❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole</td></tr> | :❑ Combination therapy: Anti-pseudomonal cephalosporin plus [[metronidazole]]</td></tr> | ||
</table></div>}} | </table></div>}} | ||
{{familytree | | |!| | | |!| | | |!| | | | |}} | {{familytree | | |!| | | |!| | | |!| | | | |}} | ||
{{familytree | | D01 | | D02 | | |!| | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">❑ Assess for infection sites<br>❑ Include CT of the chest | {{familytree | | D01 | | D02 | | |!| | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">❑ Assess for infection sites<br>❑ Include CT of the chest | ||
and sinuses to assess for invasive fungal infection</div>|D02=Continue antibiotics until ANC >500 cells/mm<sup>3</sup> and rising}} | and sinuses to assess for invasive fungal infection</div>|D02=Continue antibiotics until [[ANC]] >500 cells/mm<sup>3</sup> and rising}} | ||
{{familytree | | |!| | | |!| | | |!| | | | |}} | {{familytree | | |!| | | |!| | | |!| | | | |}} | ||
{{familytree | | E01 | | E02 | | |!| | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">❑ No changes in empirical antibiotics<br>❑ Consider continuing the empirical antibiotic therapy until ANC >500 cells/mm<sup>3</sup> and rising<br>❑ Consider modifying the empirical antibiotic coverage based on the clinical or microbiologic evidence of infections (including anti-fungal agents)<br>❑ Consider starting fluoroquinolone prophylaxis for the remaining duration of neutropenia if afebrile for 4-5 days | {{familytree | | E01 | | E02 | | |!| | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">❑ No changes in empirical antibiotics<br>❑ Consider continuing the empirical antibiotic therapy until [[ANC]] >500 cells/mm<sup>3</sup> and rising<br>❑ Consider modifying the empirical antibiotic coverage based on the clinical or microbiologic evidence of infections (including anti-fungal agents)<br>❑ Consider starting [[fluoroquinolone]] prophylaxis for the remaining duration of neutropenia if afebrile for 4-5 days | ||
:❑ Levofloxacin<br>'''or'''<br> | :❑ [[Levofloxacin]]<br>'''or'''<br> | ||
:❑ Ciprofloxacin<br> | :❑ Ciprofloxacin<br> | ||
❑ Consider switching from inpatient to outpatient oral or IV antibiotic regimens if the patients fever has subsided, combined with careful daily follow up</div>|E02=Recurrent fever during persistent neutropenia}} | ❑ Consider switching from inpatient to outpatient oral or IV antibiotic regimens if the patients fever has subsided, combined with careful daily follow up</div>|E02=Recurrent fever during persistent neutropenia}} | ||
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:❑ Until ANC >500 cells/mm<sup>3</sup> and rising<br> | :❑ Until ANC >500 cells/mm<sup>3</sup> and rising<br> | ||
'''and'''<br> | '''and'''<br> | ||
❑ Consider starting oral fluoroquinolone prophylaxis (levofloxacin or ciprofloxacin) until ANC >500 cells/mm<sup>3</sup> and rising in patients | ❑ Consider starting oral [[fluoroquinolone]] prophylaxis ([[levofloxacin]] or [[ciprofloxacin]]) until ANC >500 cells/mm<sup>3</sup> and rising in patients | ||
:❑ Who remain neutropenic after completion of appropriate treatment | :❑ 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% ">❑ 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 (antiyeast or antimold) therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | :❑ Who's signs and symptoms of a documented infection has resolved</div>|G02=<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 (antiyeast or antimold) therapy<br>❑ Broaden antimicrobial coverage for hemodynamic instability</div>}} | ||
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{{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 | | | | | | | | | 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>}} | ||
{{familytree | |!| | | | |,|-|-|^|-|-|.| | | | |!| |}} | {{familytree | |!| | | | |,|-|-|^|-|-|.| | | | |!| |}} | ||
{{familytree | C01 | | | C02 | | | | C03 | | | C04 |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Observe the patient<br>❑ No changes in the antimicrobial regimen unless signs of new infection | {{familytree | C01 | | | C02 | | | | C03 | | | C04 |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Observe the patient<br>❑ No changes in the antimicrobial regimen unless signs of new infection | ||
Line 473: | Line 473: | ||
'''or'''<br> | '''or'''<br> | ||
❑ Radiological</div>|C02=<div style="float: left; text-align: left; line-height: 150% ">'''Patients receiving antiyeast (candida) prophylaxis:'''<br> | ❑ Radiological</div>|C02=<div style="float: left; text-align: left; line-height: 150% ">'''Patients receiving antiyeast (candida) prophylaxis:'''<br> | ||
❑ Fluconazole<br> | ❑ [[Fluconazole]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Itraconazole<br> | ❑ [[Itraconazole]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Voriconazole<br> | ❑ [[Voriconazole]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Posaconazole<br> | ❑ [[Posaconazole]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Micafungin<br> | ❑ [[Micafungin]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Caspofungin<br> | ❑ [[Caspofungin]]<br> | ||
---- | ---- | ||
'''For:'''<br> | '''For:'''<br> | ||
❑ Allogeneic hematopoietic stem cell transplantation<br> | ❑ Allogeneic hematopoietic stem cell transplantation<br> | ||
'''or'''<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:''' | ❑ 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> | ❑ [[Posaconazole]]<br> | ||
---- | ---- | ||
'''For:'''<br> | '''For:'''<br> | ||
Line 505: | Line 505: | ||
:❑ Cavitary lesions<br> | :❑ Cavitary lesions<br> | ||
❑ Serial serum b-(1-3)-D glucan test for | ❑ Serial serum b-(1-3)-D glucan test for | ||
:❑ Candida species | :❑ [[Candida]] species | ||
:❑ Aspergillus species | :❑ [[Aspergillus]] species | ||
:❑ Pneumocystis species | :❑ [[Pneumocystis]] species | ||
:❑ Fusarium species<br> | :❑ [[Fusarium]] species<br> | ||
❑ Serial serum galactomannan test for | ❑ Serial serum galactomannan test for | ||
:❑ Aspergillus species<br> | :❑ [[Aspergillus]] species<br> | ||
---- | ---- | ||
'''Administer appropriate antifungal therapy if:'''<br> | '''Administer appropriate antifungal therapy if:'''<br> | ||
Line 519: | Line 519: | ||
❑ 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. candida or aspergillus species) from any body site<br> | ❑ Recovery of fungi (eg. [[candida]] or [[aspergillus]] species) from any body site<br> | ||
---- | ---- | ||
'''Withhold existing antifungal therapy if:'''<br> | '''Withhold existing antifungal therapy if:'''<br> | ||
Line 528: | Line 528: | ||
❑ 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% ">'''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>}} | ❑ 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 19:26, 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 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:
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)