Neutropenic fever: Difference between revisions
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===Outpatient=== | ===Outpatient=== | ||
#[[Ciprofloxacin]] 500mg PO q8hr AND [[Amoxicillin/Clavulanate]] 500mg PO q8hr x7d | #[[Ciprofloxacin]] 500mg PO q8hr AND [[Amoxicillin/Clavulanate]] 500mg PO q8hr x7d<ref name="antibiotics"></ref> | ||
== Disposition == | == Disposition == |
Revision as of 18:39, 17 February 2015
Background
- ANC = (total WBC) x (%segs + %bands)
- Nadir usually occurs 5-10d after chemo
- Duration of neutropenia depends on type of cancer treatment
- Solid tumor Rx: <5d
- Hematologic malignancies: 14d or longer
- (Leukemia or lymphoma) + chemo most commonly associated with neutropenia
Definition
- ANC <500 OR <1000 w/ predicted nadir of <500 in 48h AND
- Fever ≥ 38.3˚C (100.9˚F) once OR sustained temp ≥38 (100.4) for >1hr
- Oral temp (do not obtain rectal temp)
Common Causes
- Definitive cause only found in 30%
- Endogenous flora 80%
- Skin
- Staph, strep
- Respiratory tract
- Other
High-Risk/Special Infections
- Neutropenic Enterocolitis (Typhlitis)
- Mucormycosis
- Hepatosplenic Candidiasis
- Occurs after neutropenic fever resolves and ANC has come up allowing abcess formation
- Treat w/ amphotericin B
Diagnosis
- 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
Work-Up
- AVOID rectal temp
- CBC
- Chemistry
- LFTs
- UA/UCx
- May not show WBCs or leuk esterase given neutropenia
- Sputum studies
- Gram stain
- Cx
- BCx x 2
- 20-30cc blood (adult); 3-9cc (child)
- May take both samples from CVC (if present)
- Cx any indwelling catheters
- LP
- If neuro abnl or suspicious
- Site-specific specimens
- Stool (if indicated)
- C dif
- O&P
- Cx
- CXR
- CT (if necessary)
- Sinuses
- Chest
- A/P
Treatment
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[1]
- 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:[2]
- 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 500mg PO q8hr AND Amoxicillin/Clavulanate 500mg PO q8hr x7d[1]
Disposition
- Low risk patients
- Consider discharge it pt scores ≥21 using the MASCC risk index scoring system
- Score ≥21 associated w/ <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.[3]
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 | 3 |
Outpatient status | 3 |
Age <60yr | 2 |
Source
- ↑ 1.0 1.1 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
- ↑ 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
- ↑ 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.