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

  1. ANC <500 OR <1000 w/ predicted nadir of <500 in 48h AND
  2. Fever ≥ 38.3˚C (100.9˚F) once OR sustained temp ≥38 (100.4) for >1hr
    1. Oral temp (do not obtain rectal temp)

Common Causes

  • Definitive cause only found in 30%
  1. Endogenous flora 80%
    1. E. Coli, Enterobacter, anaerobes
  2. Skin
    1. Staph, strep
  3. Respiratory tract
    1. Step pneumonia, klebsiella, corynebacterium, pseudomonas
  4. Other
    1. C. diff, mycobacterium, candida, Aspergillus

High-Risk/Special Infections

  1. Neutropenic Enterocolitis (Typhlitis)
  2. Mucormycosis
  3. Hepatosplenic Candidiasis
    1. Occurs after neutropenic fever resolves and ANC has come up allowing abcess formation
    2. Treat w/ amphotericin B

Diagnosis

  1. Classic manifestations of infection are frequently NOT seen
  2. Check skin, oral cavity, perianal area, entry sites of indwelling cath sites

Differential Diagnosis

Work-Up

  1. AVOID rectal temp
  2. CBC
  3. Chemistry
  4. LFTs
  5. UA/UCx
    1. May not show WBCs or leuk esterase given neutropenia
  6. Sputum studies
    1. Gram stain
    2. Cx
  7. BCx x 2
    1. 20-30cc blood (adult); 3-9cc (child)
    2. May take both samples from CVC (if present)
  8. Cx any indwelling catheters
  9. LP
    1. If neuro abnl or suspicious
  10. Site-specific specimens
    1. Nasopharyngeal wash (in pts with URI)
      1. RSV, influenza
  11. Stool (if indicated)
    1. C dif
    2. O&P
    3. Cx
  12. CXR
  13. CT (if necessary)
    1. Sinuses
    2. Chest
    3. 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

Outpatient

  1. 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. 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
  2. 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
  3. 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.