Neutropenic fever: Difference between revisions
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{{Neutropenic fever treatment}} | {{Neutropenic fever treatment}} | ||
== Disposition | == Disposition == | ||
*Low risk patients | *Low risk patients | ||
**Consider discharge it patient scores ≥21 using the MASCC risk index scoring system | **Consider discharge it patient scores ≥21 using the MASCC risk index scoring system | ||
**Score ≥21 associated w/ <5% risk for severe complications and mortality <1% | **Score ≥21 associated w/ <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" | ||
Revision as of 14:43, 6 July 2016
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
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
Diagnosis
- AVOID rectal temp
- CBC
- Chemistry
- LFTs
- UA/UCx
- 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)
- 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 750mg PO q12hrs AND Amoxicillin/Clavulanate 875mg PO q12hrs x7d OR[1]
- Ciprofloxacin 750mg PO q12hrs AND Clindamycin 450mg PO q8hrs
Disposition
- Low risk patients
- Consider discharge it patient 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 requiring IV fluids | 3 |
| Outpatient status at fever onset | 3 |
| Age <60yr | 2 |
References
- ↑ 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 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
- ↑ 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.