Neutropenic fever: Difference between revisions
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==Background== | ==Background== | ||
{{Neutropenia background}} | |||
{{Neutropenic fever definition}} | |||
===Common Causes=== | ===Common Causes=== | ||
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**[[E. Coli]], [[Enterobacter]], [[anaerobes]] | **[[E. Coli]], [[Enterobacter]], [[anaerobes]] | ||
*Skin | *Skin | ||
**Staph, strep | **[[Staph]], [[strep]] | ||
*Respiratory tract | *Respiratory tract | ||
**[[Step pneumonia]], [[klebsiella]], [[corynebacterium]], [[pseudomonas]] | **[[Step pneumonia]], [[klebsiella]], [[corynebacterium]], [[pseudomonas]] | ||
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*[[Mucormycosis]] | *[[Mucormycosis]] | ||
*Hepatosplenic Candidiasis | *Hepatosplenic Candidiasis | ||
**Occurs after neutropenic fever resolves and ANC has come up allowing | **Occurs after neutropenic fever resolves and ANC has come up allowing abscess formation | ||
**Treat | **Treat with [[amphotericin B]] | ||
==Clinical Features== | ==Clinical Features== | ||
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{{Oncologic emergencies DDX}} | {{Oncologic emergencies DDX}} | ||
== | ==Evaluation== | ||
'''AVOID rectal temp''' | |||
*CBC | *CBC | ||
*Chemistry | *Chemistry | ||
*LFTs | *LFTs | ||
* | *[[Urinalysis]]/Urine culture | ||
**May not show WBCs or leuk esterase given neutropenia | **May not show WBCs or leuk esterase given neutropenia | ||
*Sputum studies | *Sputum studies | ||
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**20-30cc blood (adult); 3-9cc (child) | **20-30cc blood (adult); 3-9cc (child) | ||
**May take both samples from CVC (if present) | **May take both samples from CVC (if present) | ||
* | *Culture any indwelling catheters | ||
*[[LP]] | *[[LP]] | ||
**If neuro | **If neuro findings or suspicious | ||
*Site-specific specimens | *Site-specific specimens | ||
**Nasopharyngeal wash (in | **Nasopharyngeal wash (in patients with URI) | ||
***[[RSV]], [[influenza]] | ***[[RSV]], [[influenza]] | ||
*Stool (if indicated) | *Stool (if indicated) | ||
**[[C dif]] | **[[C dif]] | ||
**O&P | **O&P | ||
** | **Cultures | ||
*CXR | *[[CXR]] | ||
*CT (if necessary) | *CT (if necessary) | ||
**Sinuses | **Sinuses | ||
**Chest | **Chest | ||
**A/P | **A/P | ||
*Patient should be placed and maintained on neutropenic isolation precautions during there stay in the ED and while in the hospital | |||
== | ==Management== | ||
{{Neutropenic fever treatment}} | {{Neutropenic fever treatment}} | ||
== Disposition | ==Disposition== | ||
*Low risk patients | *Low risk patients | ||
**Consider discharge it | **Brief (<7d duration) of neutropenia with few comorbidities<ref>Freifeld AG et al. Clinical practice guideline for the use of antimicrobial agents in | ||
**Score ≥21 associated | neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93.</ref> | ||
**Consider discharge it patient scores ≥21 using the MASCC risk index scoring system | |||
**Score ≥21 associated with <5% risk for severe complications and mortality <1% | |||
=== MASCC Risk Index === | ===MASCC Risk Index=== | ||
*The MASCC study was an international collaboration to derive and validate a scoring system to identify low-risk patients for complications of febrile neutropenia.<ref>Klatersky et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Onc 18:3038-3051.</ref> | *The MASCC study was an international collaboration to derive and validate a scoring system to identify low-risk patients for complications of febrile neutropenia.<ref>Klatersky et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Onc 18:3038-3051.</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
| Characteristic | | '''Characteristic ''' | ||
| Points | | '''Points''' | ||
|- | |- | ||
| | | | ||
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|- | |- | ||
| No Hypotension (SBP | | No [[Hypotension]](SBP<90) | ||
| 5 | | 5 | ||
|- | |- | ||
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| 4 | | 4 | ||
|- | |- | ||
| Solid tumor OR no previous fungal infection | | Solid tumor '''OR''' no previous fungal infection | ||
| 4 | | 4 | ||
|- | |- | ||
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| 3 | | 3 | ||
|- | |- | ||
| Age | | Age <60yr | ||
| 2 | | 2 | ||
|} | |} | ||
===CISNE=== | |||
*Clinical Index of Stable febrile Neutropenia | |||
*230 febrile neutropenia, chemo-therapy induced, retrospective analysis of MASCC vs. CISNE<ref>Coyne et al. Application of the MASCC and CISNE Risk-stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department. Ann Emerg Med. 2016 Dec 29. pii: S0196-0644(16)31352-X. doi: 10.1016/j.annemergmed.2016.11.007.</ref> | |||
**MASCC was ~55% specific and CISNE was ~98% specific with PPV ~98% | |||
==See Also== | |||
*[[Neutropenia]] | |||
==References== | ==References== |
Revision as of 16:08, 26 March 2018
Background
Neutropenia
- ANC = (total WBC) x (%segs + %bands)
- Nadir usually occurs 5-10d after chemo
- Duration of neutropenia depends on type of cancer treatment
- Solid tumor treatments: <5d
- Hematologic malignancies: 14d or longer
- (Leukemia or lymphoma) + chemo most commonly associated with neutropenia
Neutropenic fever definition
- ANC <500 OR <1000 with predicted nadir of <500 in 48h AND
- Fever ≥ 38.3˚C (100.9˚F) once OR sustained temperature ≥38 (100.4) for >1hr
- Oral temperature (do not obtain rectal temp; risk of inducing bacteremia[1])
Common Causes
Definitive cause only found in 30%
- Endogenous flora 80%
- Skin
- Respiratory tract
- Other
High-Risk/Special Infections
- Neutropenic Enterocolitis (Typhlitis)
- Mucormycosis
- Hepatosplenic Candidiasis
- Occurs after neutropenic fever resolves and ANC has come up allowing abscess formation
- Treat with amphotericin B
Clinical Features
- Fever
- Classic manifestations of infection are frequently NOT seen
- Check skin, oral cavity, perianal area, entry sites of indwelling cath sites
Differential Diagnosis
- Transfusion reaction
- Medication allergies and toxicities
- Tumor-related fever
Oncologic Emergencies
Related to Local Tumor Effects
- Malignant airway obstruction
- Bone metastases and pathologic fractures
- Malignant spinal cord compression
- Malignant Pericardial Effusion and Tamponade
- Superior vena cava syndrome
Related to Biochemical Derangement
- Hypercalcemia of malignancy
- Hyponatremia due to SIADH
- Adrenal insufficiency
- Tumor lysis syndrome
- Carcinoid syndrome
Related to Hematologic Derangement
Related to Therapy
- Chemotherapy-induced nausea and vomiting
- Cytokine release syndrome
- Chemotherapeutic drug extravasation
- Differentiation syndrome (retinoic acid syndrome) in APML
- Stem cell transplant complications
- Catheter-related complications
- Tunnel infection
- Exit site infection
- CVC obstruction (intraluminal or catheter tip thrombosis)
- Catheter-related venous thrombosis
- Fracture of catheter lumen
- Oncologic therapy related adverse events
Evaluation
AVOID rectal temp
- CBC
- Chemistry
- LFTs
- Urinalysis/Urine culture
- May not show WBCs or leuk esterase given neutropenia
- Sputum studies
- Gram stain
- Culture
- Blood culture x 2
- 20-30cc blood (adult); 3-9cc (child)
- May take both samples from CVC (if present)
- Culture any indwelling catheters
- LP
- If neuro findings or suspicious
- Site-specific specimens
- Stool (if indicated)
- C dif
- O&P
- Cultures
- CXR
- CT (if necessary)
- Sinuses
- Chest
- A/P
- Patient should be placed and maintained on neutropenic isolation precautions during there stay in the ED and while in the hospital
Management
Therapy is aimed at treating multiple flora that include Gram Negatives, Gram Positive Bacteria, Pseudomonas and if there is an indwelling catheter or high risk, then MRSA.
Inpatient
- Monotherapy appears to be as good as dual-drug therapy[2]
- Cefepime 2g IV q8hr or Ceftazidime 2g IV q8hr OR
- Imipenem/Cilastin 1gm IV q8hr or Meropenem 1gm IV q8hr OR
- Piperacillin/Tazobactam 4.5gm IV q 6hr
- Consider adding Vancomycin to above regimen for:[3]
- Severe mucositis
- Signs of catheter site infection
- Fluoroquinolone prophylaxis was recently used against gram-negative bacteremia
- Hypotension is present
- Institutions with hospital-associated MRSA
- Patient has known colonization with resistant gram-positive organisms
Outpatient
- Ciprofloxacin 750mg PO q12hrs AND Amoxicillin/Clavulanate 875mg PO q12hrs x7d OR[2]
- Ciprofloxacin 750mg PO q12hrs AND Clindamycin 450mg PO q8hrs
Disposition
- Low risk patients
- Brief (<7d duration) of neutropenia with few comorbidities[4]
- Consider discharge it patient scores ≥21 using the MASCC risk index scoring system
- Score ≥21 associated with <5% risk for severe complications and mortality <1%
MASCC Risk Index
- The MASCC study was an international collaboration to derive and validate a scoring system to identify low-risk patients for complications of febrile neutropenia.[5]
Characteristic | Points |
No or Mild Symptoms Moderate Symptoms Severe Symptoms |
5 3 0 |
No Hypotension(SBP<90) | 5 |
No COPD | 4 |
Solid tumor OR no previous fungal infection | 4 |
No dehydration requiring IV fluids | 3 |
Outpatient status at fever onset | 3 |
Age <60yr | 2 |
CISNE
- Clinical Index of Stable febrile Neutropenia
- 230 febrile neutropenia, chemo-therapy induced, retrospective analysis of MASCC vs. CISNE[6]
- MASCC was ~55% specific and CISNE was ~98% specific with PPV ~98%
See Also
References
- ↑ Fleischman RJ. Emergency Complications of Malignancy. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed December 09, 2020. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158§ionid=162273381
- ↑ 2.0 2.1 Friefeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93 fulltext
- ↑ Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clinical Infectious Disease 2002; 34:730-751
- ↑ Freifeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93.
- ↑ Klatersky et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Onc 18:3038-3051.
- ↑ Coyne et al. Application of the MASCC and CISNE Risk-stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department. Ann Emerg Med. 2016 Dec 29. pii: S0196-0644(16)31352-X. doi: 10.1016/j.annemergmed.2016.11.007.