Febrile neutropenia resident survival guide: Difference between revisions
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{{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} | {{familytree | | | | | | | E01 | | | | | |E01= '''DO A RISK ASSESSMENT'''}} | ||
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{{familytree | | | | F01 | | | | F02 | | |F01= <div style="float: left; text-align: left; line-height: 150% ">'''LOW RISK'''<br>❑ MASCC score* ≥21, OR <br>❑ | {{familytree | | | | F01 | | | | F02 | | |F01= <div style="float: left; text-align: left; line-height: 150% ">'''LOW RISK'''<br>❑ MASCC score* ≥21, OR <br>❑ Expected brief neutropenia (≤ 7 days), OR <br>❑ Clinically stable patient, OR <br>❑ No comorbidities </div> | ||
| F02= <div style="float: left; text-align: left; line-height: 150% ">'''HIGH RISK'''<br> | | F02= <div style="float: left; text-align: left; line-height: 150% ">'''HIGH RISK'''<br> | ||
❑ MASCC score* <21, OR <br> | ❑ MASCC score* <21, OR <br> | ||
❑ | ❑ Expected prolonged neutropenia (> 7 days) AND profound neutropenia (ANC≤100 cells mm<sup>3</sup>), AND/OR <br> | ||
❑ Presence of comorbidities </div>}} | ❑ Presence of comorbidities </div>}} | ||
{{familytree | | |,|-|^|-|.| | | |!| | | |}} | {{familytree | | |,|-|^|-|.| | | |!| | | |}} |
Revision as of 14:08, 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
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.
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
Initial Management
Confirm fever and neutropenia: ❑ Single oral temperature ≥38.3°c (101°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 ❑ Expected 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: | |||||||||||||||||||||||||||||
Management 2 to 4 Days After Initiation of Antibiotic Treatment
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.