Febrile neutropenia: Difference between revisions

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| style="vertical-align: middle; padding: 5px;" align=center | [[File:Siren.gif|30px|link=Cardiogenic shock resident survival guide]]
| [[File:Siren.gif|30px|link=Febrile neutropenia resident survival guide]]|| <br> || <br>
| style="vertical-align: middle; padding: 5px;" align=center | [[Cardiogenic shock resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
| [[Febrile neutropenia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{SK}} FN, febrile leukopenia, neutropenic fever, neutropenic fever syndrome, neutropenic sepsis, hot and low, F and N, a hot leuk
{{SK}} F and N; FN; neutropenic fever; neutropenic fever syndrome


==Overview==
== Overview ==
'''Febrile neutropenia''' is the development of [[fever]], often with other signs of [[infection]], in a patient with [[neutropenia]], an abnormally low number of [[neutrophil granulocyte]]s (a type of [[white blood cell]]) in the blood. The term '''neutropenic sepsis''' is also applied, although it tends to be reserved for patients who are less well. In 50% of cases, an infection is detectable; [[bacteremia]] (bacteria in the bloodstream) is present in approximately 20% of all patients with this condition.<ref name="pmid11850858">{{cite journal |author=Hughes WT, Armstrong D, Bodey GP, ''et al.'' |title=2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer |journal=Clin. Infect. Dis. |volume=34 |issue=6 |pages=730–51 |year=2002 |pmid=11850858 |doi=10.1086/339215| url=http://www.journals.uchicago.edu/doi/full/10.1086/339215 |month= March|issn=1058-4838}}</ref>
'''Febrile neutropenia''' is the development of [[fever]], often with other signs of [[infection]], in a patient with [[neutropenia]], an abnormally low number of [[neutrophil granulocyte]]s (a type of [[white blood cell]]) in the blood. The term '''neutropenic sepsis''' is also applied, although it tends to be reserved for patients who are less well. In 50% of cases, an infection is detectable; [[bacteremia]] (bacteria in the bloodstream) is present in approximately 20% of all patients with this condition.<ref name="pmid11850858">{{cite journal |author=Hughes WT, Armstrong D, Bodey GP, ''et al.'' |title=2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer |journal=Clin. Infect. Dis. |volume=34 |issue=6 |pages=730–51 |year=2002 |pmid=11850858 |doi=10.1086/339215| url=http://www.journals.uchicago.edu/doi/full/10.1086/339215 |month= March|issn=1058-4838}}</ref>


==Causes==
== Historical Perspective ==
 
 
 
== Pathophysiology ==
 
 
 
== Causes ==
* Febrile neutropenia can develop in any form of neutropenia, but is most generally recognized as a complication of [[chemotherapy]] when it is [[myelosuppressive]] (suppresses the [[bone marrow]] from producing blood cells).
* Febrile neutropenia can develop in any form of neutropenia, but is most generally recognized as a complication of [[chemotherapy]] when it is [[myelosuppressive]] (suppresses the [[bone marrow]] from producing blood cells).
* Medication induced:[[caspofungin acetate]], [[Cyclophosphamide]], [[Eribulin]], [[Nelarabine]], [[Pertuzumab]]
* Medication induced:[[caspofungin acetate]], [[Cyclophosphamide]], [[Eribulin]], [[Nelarabine]], [[Pertuzumab]]


==Multinational Association for Supportive Care in Cancer (MASCC) Risk Index==
=== Life Threatening Causes ===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
 
=== Common Causes ===
 
=== Causes by Organ System ===
 
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}
 
=== Causes in Alphabetical Order ===
 
 
 
== Epidemiology and Demographics ==
 
 
 
 
== Risk Factors ==
 
== Natural History, Complications and Prognosis ==
 
 
 
== Diagnosis ==
=== Diagnostic Criteria ===
 
=== History ===
 
 
=== Symptoms ===
 
=== Physical Examination ===
 
 
=== Laboratory Findings ===
 
 
 
 
== Multinational Association for Supportive Care in Cancer (MASCC) Risk Index ==
The Multinational Association for Supportive Care in Cancer (MASCC) Risk Index can be used to identify high-risk patients (score <21) and low-risk patients (score ≥21 points) for serious complications of febrile neutropenia (including death, [[intensive care unit]] admission, confusion, cardiac complications, [[respiratory failure]], [[renal failure]], [[hypotension]], [[bleeding]], and other serious medical complications).<ref name="pmid10944139">{{cite journal |author=Klastersky J, Paesmans M, Rubenstein EB, ''et al.'' |title=The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients.|journal= J Clin Oncol. |volume=18 |issue=16 |pages=3038–51 |date=16 August 2000|pmid=10944139| url=http://jco.ascopubs.org/cgi/content/full/18/16/3038 |issn=0732-183X}}</ref>  The score was developed to select patients for therapeutic strategies that could potentially be more convenient or cost-effective.  The various variables and the weight of individual variables used in the MASCC risk index is as follows.  To summarize, risk assessment helps determining the type of empirical antibiotic therapy, venue of the treatment, and duration of the antibiotic therapy.
The Multinational Association for Supportive Care in Cancer (MASCC) Risk Index can be used to identify high-risk patients (score <21) and low-risk patients (score ≥21 points) for serious complications of febrile neutropenia (including death, [[intensive care unit]] admission, confusion, cardiac complications, [[respiratory failure]], [[renal failure]], [[hypotension]], [[bleeding]], and other serious medical complications).<ref name="pmid10944139">{{cite journal |author=Klastersky J, Paesmans M, Rubenstein EB, ''et al.'' |title=The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients.|journal= J Clin Oncol. |volume=18 |issue=16 |pages=3038–51 |date=16 August 2000|pmid=10944139| url=http://jco.ascopubs.org/cgi/content/full/18/16/3038 |issn=0732-183X}}</ref>  The score was developed to select patients for therapeutic strategies that could potentially be more convenient or cost-effective.  The various variables and the weight of individual variables used in the MASCC risk index is as follows.  To summarize, risk assessment helps determining the type of empirical antibiotic therapy, venue of the treatment, and duration of the antibiotic therapy.


Line 43: Line 201:
A prospective trial demonstrated that a modified MASCC score can identify patients with febrile neutropenia at low risk of complications as well.<ref name="pmid17960431">{{cite journal |author=de Souza Viana L, Serufo JC, da Costa Rocha MO, Costa RN, Duarte RC |title=Performance of a modified MASCC index score for identifying low-risk febrile neutropenic cancer patients |journal=Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer |volume=16 |issue=7 |pages=841–6 |year=2008 |month=July |pmid=17960431 |doi=10.1007/s00520-007-0347-3 |issn=0941-4355}}</ref>
A prospective trial demonstrated that a modified MASCC score can identify patients with febrile neutropenia at low risk of complications as well.<ref name="pmid17960431">{{cite journal |author=de Souza Viana L, Serufo JC, da Costa Rocha MO, Costa RN, Duarte RC |title=Performance of a modified MASCC index score for identifying low-risk febrile neutropenic cancer patients |journal=Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer |volume=16 |issue=7 |pages=841–6 |year=2008 |month=July |pmid=17960431 |doi=10.1007/s00520-007-0347-3 |issn=0941-4355}}</ref>


==Treatment==
== Treatment ==
Generally, patients with febrile neutropenia are treated with empirical [[antibiotic]]s until the neutrophil count has recovered (Absolute neutrophil counts greater than 500/mm3) and the fever has abated; if the neutrophil count does not improve, treatment may need to continue for two weeks or occasionally more. In cases of recurrent or persistent fever, an antifungal agent should be added.  
Generally, patients with febrile neutropenia are treated with empirical [[antibiotic]]s until the neutrophil count has recovered (Absolute neutrophil counts greater than 500/mm3) and the fever has abated; if the neutrophil count does not improve, treatment may need to continue for two weeks or occasionally more. In cases of recurrent or persistent fever, an antifungal agent should be added.  


Line 50: Line 208:
In 2010, an updated guidelines was issued by the [[Infectious Diseases Society of America]], recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), piperacillin/tazobactam for high risk patients and [[co-amoxiclav]] and [[ciprofloxacin]] for low risk patients. Patients who do not strictly fulfill the criteria of 'low risk patients' should be admitted to the hospital and treat as high risk patients.
In 2010, an updated guidelines was issued by the [[Infectious Diseases Society of America]], recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), piperacillin/tazobactam for high risk patients and [[co-amoxiclav]] and [[ciprofloxacin]] for low risk patients. Patients who do not strictly fulfill the criteria of 'low risk patients' should be admitted to the hospital and treat as high risk patients.


==See also==
== See Also ==
*[[Neutropenia]]
*[[Neutropenia]]
*[[Leukocytopenia]]
*[[Leukopenia]]
*[[Fever]]
*[[Fever]]
*[[Myelosuppression]]
*[[Myelosuppression]]

Revision as of 15:32, 6 February 2015

Resident
Survival
Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: F and N; FN; neutropenic fever; neutropenic fever syndrome

Overview

Febrile neutropenia is the development of fever, often with other signs of infection, in a patient with neutropenia, an abnormally low number of neutrophil granulocytes (a type of white blood cell) in the blood. The term neutropenic sepsis is also applied, although it tends to be reserved for patients who are less well. In 50% of cases, an infection is detectable; bacteremia (bacteria in the bloodstream) is present in approximately 20% of all patients with this condition.[1]

Historical Perspective

Pathophysiology

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

Causes by Organ System

Cardiovascular No underlying causes
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Dental No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History

Symptoms

Physical Examination

Laboratory Findings

Multinational Association for Supportive Care in Cancer (MASCC) Risk Index

The Multinational Association for Supportive Care in Cancer (MASCC) Risk Index can be used to identify high-risk patients (score <21) and low-risk patients (score ≥21 points) for serious complications of febrile neutropenia (including death, intensive care unit admission, confusion, cardiac complications, respiratory failure, renal failure, hypotension, bleeding, and other serious medical complications).[2] The score was developed to select patients for therapeutic strategies that could potentially be more convenient or cost-effective. The various variables and the weight of individual variables used in the MASCC risk index is as follows. To summarize, risk assessment helps determining the type of empirical antibiotic therapy, venue of the treatment, and duration of the antibiotic therapy.

Characteristic Score
No or mild symptoms in patients following an episode of febrile neutropenia 5
Absence of hypotension with a systolic blood pressure >90 mmHg 5
No chronic obstructive pulmonary disease (active chronic bronchitis, emphysema, decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or bronchodilators) 4
Solid tumor or hematologic malignancy with no previously demonstrated fungal infection or empirically treated suspected fungal infection 4
Absence of dehydration that requires parenteral fluids 3
Moderate symptoms in patients following an episode of febrile neutropenia 3
Outpatient status 3
Age <60 years 2

A prospective trial demonstrated that a modified MASCC score can identify patients with febrile neutropenia at low risk of complications as well.[3]

Treatment

Generally, patients with febrile neutropenia are treated with empirical antibiotics until the neutrophil count has recovered (Absolute neutrophil counts greater than 500/mm3) and the fever has abated; if the neutrophil count does not improve, treatment may need to continue for two weeks or occasionally more. In cases of recurrent or persistent fever, an antifungal agent should be added.

Guidelines issued in 2002 by the Infectious Diseases Society of America recommend the use of particular combinations of antibiotics in specific settings; mild low-risk cases may be treated with a combination of oral co-amoxiclav and ciprofloxacin, while more severe cases require cephalosporins with activity against Pseudomonas aeruginosa (e.g. cefepime), or carbapenems (imipenem or meropenem).[1] A subsequent meta-analysis published in 2006 found that cefepime was associated with more negative outcomes, and that carbapenems (while causing a higher rate of pseudomembranous colitis) were the most straightforward in use.[4]

In 2010, an updated guidelines was issued by the Infectious Diseases Society of America, recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), piperacillin/tazobactam for high risk patients and co-amoxiclav and ciprofloxacin for low risk patients. Patients who do not strictly fulfill the criteria of 'low risk patients' should be admitted to the hospital and treat as high risk patients.

See Also

References

  1. ↑ 1.0 1.1 Hughes WT, Armstrong D, Bodey GP; et al. (2002). "2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer". Clin. Infect. Dis. 34 (6): 730–51. doi:10.1086/339215. ISSN 1058-4838. PMID 11850858. Unknown parameter |month= ignored (help)
  2. ↑ Klastersky J, Paesmans M, Rubenstein EB; et al. (16 August 2000). "The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients". J Clin Oncol. 18 (16): 3038–51. ISSN 0732-183X. PMID 10944139.
  3. ↑ de Souza Viana L, Serufo JC, da Costa Rocha MO, Costa RN, Duarte RC (2008). "Performance of a modified MASCC index score for identifying low-risk febrile neutropenic cancer patients". Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer. 16 (7): 841–6. doi:10.1007/s00520-007-0347-3. ISSN 0941-4355. PMID 17960431. Unknown parameter |month= ignored (help)
  4. ↑ Paul M, Yahav D, Fraser A, Leibovici L (2006). "Empirical antibiotic monotherapy for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials". J. Antimicrob. Chemother. 57 (2): 176–89. doi:10.1093/jac/dki448. ISSN 0305-7453. PMID 16344285. Unknown parameter |month= ignored (help)

External links

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