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Neutropenic fever
From WikEM
Contents
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)
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 abcess 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
- Neutropenic fever
- Leukostasis and hyperleukocytosis
- Hyperviscosity syndrome
- Thromboembolism
Related to Therapy
- Chemotherapy-induced nausea and vomiting
- Chemotherapeutic drug extravasation
- Differentiation syndrome (retinoic acid syndrome) in APML
- Stem cell transplant complications
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
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[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 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.[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 |
CISNE
- Clinical Index of Stable febrile Neutropenia
- 230 febrile neutropenia, chemo-therapy induced, retrospective analysis of MASCC vs. CISNE[4]
- MASCC was ~55% specific and CISNE was ~98% specific with PPV ~98%
See Also
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.
- ↑ 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.
