Febrile neutropenia resident survival guide: Difference between revisions
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❑ Presence of comorbidities </div>}} | ❑ Presence of comorbidities </div>}} | ||
{{familytree | | |,|-|^|-|.| | | |!| | | |}} | {{familytree | | |,|-|^|-|.| | | |!| | | |}} | ||
{{familytree | | H01 | | H02 | | H03 | | |H01= <div style="float: left; text-align: left; line-height: 150% ">'''Outpatient oral antibiotics'''<br> | {{familytree | | H01 | | H02 | | H03 | | |H01= <div style="float: left; text-align: left; line-height: 150% ">'''Outpatient oral antibiotics (Urgent)'''<br> | ||
❑ Ability to tolerate oral medications<br> | ❑ Ability to tolerate oral medications<br> | ||
❑ Availabilty of telephone, transportation to hospital, caregiver<br></div> | ❑ Availabilty of telephone, transportation to hospital, caregiver<br></div> | ||
| H02= <div style="float: left; text-align: left; line-height: 150% ">'''Inpatient IV antibiotics'''<br> | | H02= <div style="float: left; text-align: left; line-height: 150% ">'''Inpatient IV antibiotics (Urgent)'''<br> | ||
❑ Inability to tolerate oral medications<br> | ❑ Inability to tolerate oral medications<br> | ||
❑ Unavailabilty of telephone, transportation to hospital, caregiver<br> | ❑ Unavailabilty of telephone, transportation to hospital, caregiver<br> | ||
❑ Identified infection necessitating IV antibiotics</div> | ❑ Identified infection necessitating IV antibiotics</div> | ||
| H03='''Inpatient IV antibiotics'''<br>}} | | H03='''Inpatient IV antibiotics (Urgent)'''<br>}} | ||
{{familytree | | |!| | | | | | | |!| | | |}} | {{familytree | | |!| | | | | | | |!| | | |}} | ||
{{familytree | | I01 | | | | | | I02 | | |I01= <div style="float: left; text-align: left; line-height: 150% ">'''Administer oral antibiotics:'''<br> ❑ [[ciprofloxacin]] + [[amoxicillin]]/[[clavulanate]]<br> | {{familytree | | I01 | | | | | | I02 | | |I01= <div style="float: left; text-align: left; line-height: 150% ">'''Administer oral antibiotics:'''<br> ❑ [[ciprofloxacin]] + [[amoxicillin]]/[[clavulanate]]<br> | ||
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| I02= |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Administer IV monotherapy with an antipseudomonal:'''<br>❑ [[Cefepime]], OR<br>❑ [[Piperacillin]]/[[tazobactam]], OR<br>❑ [[Carbapenem]]</div>}} | | I02= |I02= <div style="float: left; text-align: left; line-height: 150% ">'''Administer IV monotherapy with an antipseudomonal:'''<br>❑ [[Cefepime]], OR<br>❑ [[Piperacillin]]/[[tazobactam]], OR<br>❑ [[Carbapenem]]</div>}} | ||
{{familytree | | | | | | | | | | |!| | | |}} | {{familytree | | | | | | | | | | |!| | | |}} | ||
{{familytree | | | | | | | | | | J02 | | |J02= }} | {{familytree | | | | | | | | | | J02 | | |J02= <div style="float: left; text-align: left; line-height: 150% ">'''Modify antibiotics if necessary:'''<br> | ||
'''Add [[vancomycin]] if:'''<br> | |||
❑ Suspected catheter related infection<br>❑ Suspected skin or soft tissue infection<br>❑ Suspected [[pneumonia]]<br>❑ Hemodynamic instability<br> | |||
---- | |||
'''Cover for organisms in case of previous infection, colonization, high endemicity:'''<br> | |||
❑ [[MRSA]]: Add [[vancomycin]], or [[linezolid]] or [[daptomycin]]<br> | |||
❑ [[VRE]]: Add [[linezolid]] or [[daptomycin]]<br> | |||
❑ [[ESBL]]: Add [[carbapenem]]<br> | |||
❑ [[KPC]]: Add [[polymyxin]], [[colistin]] or [[tigecycline]] | |||
</div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 02:46, 23 December 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Definition
Fever in a neutropenic patients is defined as one oral temperature of >38.3°C (101°F) or a temperature of >38.0°C (100.4°F) for >1 hour. Neutropenia is defined as an absolute neutrophil count (ANC) <1500 cells/microL. Severe neutropenia is defined when the ANC <500 cells/microL, or an ANC that is expected to decrease to <500 cells/microL over the next 48 hours. Clinically significant infections usually occurs with severe neutropenia
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
Shown below is an algorithm summarizing the approach to febrile neutropenia.
Confirm fever and neutropenia: ❑ Single oral temperature ≥38.3°c (1010.4°F), OR | |||||||||||||||||||||||||||||
Obtain a detailed history: ❑ New site specific onset | |||||||||||||||||||||||||||||
Examine the patient: ❑ Site of previous procedures (entry and exit sites of catheters, bone marrow aspiration site) | |||||||||||||||||||||||||||||
Order lab tests and cultures: Labs every 3 days during the course of antibiotics: Labs weekly during the course of antibiotics Cultures: Additional tests (not routine) | |||||||||||||||||||||||||||||
DO A RISK ASSESSMENT | |||||||||||||||||||||||||||||
LOW RISK ❑ MASCC score* ≥21, OR ❑ Anticipated brief neutropenia (≤ 7 days), OR ❑ Clinically stable patient, OR ❑ No comorbidities | HIGH RISK ❑ MASCC score* <21, OR | ||||||||||||||||||||||||||||
Outpatient oral antibiotics (Urgent) ❑ Ability to tolerate oral medications | Inpatient IV antibiotics (Urgent) ❑ Inability to tolerate oral medications | Inpatient IV antibiotics (Urgent) | |||||||||||||||||||||||||||
Administer oral antibiotics: ❑ ciprofloxacin + amoxicillin/clavulanate Observe and discharge: | Administer IV monotherapy with an antipseudomonal: ❑ Cefepime, OR ❑ Piperacillin/tazobactam, OR ❑ Carbapenem | ||||||||||||||||||||||||||||
Modify antibiotics if necessary: Add vancomycin if: Cover for organisms in case of previous infection, colonization, high endemicity: | |||||||||||||||||||||||||||||