[22] Febrile Neutropenia Flashcards
When is febrile netropenia most often seen?
As a result of cytotoxic therapy
When does the neutrophil count usually reach its lowest level?
5-10 days after the last dose of chemotherapy
Other than after cytotoxic therapy, when can neutropenia occur in cancer?
- After radiotherapy
- Part of pancytopenia
When can neutropenia follow radiotherapy?
When large volumes of bone marrow are irradiated
Why might cancer cause pancytopenia?
Due to malignant infiltration of the marrow
What is febrile neutropenia defined as?
- Oral temperature of 38.5 or above, and 2 consecutive readings of 38 or above for 2 hours
- Absolute neutrophil count of 0.5x10^9/L or less
When should there be a high index of suspicion for febrile neutropenia?
In all patients who have recently received chemotherapy
What is the significance of fever in a cancer patient?
Although there are other causes of fever in a cancer patient, infection should always be assumed unless proven otherwise
Are the signs and symptoms of febrile neutropenia significant?
No, they can be minimal
When in particular might the signs and symptoms of febrile neutropenia be minimal?
In patients on corticosteroids
What should the history include in febrile neutropenia?
- Whether the patient belongs to a high risk group
- Duration since last chemotherapy cycle (if applicable)
- Any recent blood produces
- Any intravascular devices, e.g. cannula, central lines
What are the high risk groups for febrile neutropenia?
- Active neoplastic disease
- Recent course of chemotherapy
- Immunosuppressant therapy
- Immunosuppressive illness, e.g. HIV
- CKD
What laboratory investigations should be done in febrile neutropenia?
Infection screen comprising of;
- Blood cultures
- MSU
- Chest x-ray
- Swabs for cultures
What blood cultures should be done in febrile neutropenia?
- Peripheral
- Central line if present
What swabs should be done in febrile neutropenia?
- Throat
- Central line site
Are additional microbiological assessments required in febrile neutropenia?
Not unless there are localising signs of infection
What is the basic management of febrile neutropenia?
Sepsis 6 bundle
What should choice of empirical antibiotics be based on in febrile neutropenia?
Local hospital policies, agreed with microbiologists and based on local antibiotic resistance patterns
What is first line empirical antibiotic therapy in febrile neutropenia?
Either monotherapy with tazocin or meropenum, or with the addition of gentamicin
What can be added to empirical antibiotic therapy for febrile neutropenia when anaerobic infection is present?
Metronidazole
What can be added to empirical antibiotic therapy for febrile neutropenia when gram-positive infection is suspected?
One of;
- Flucloxacillin
- Vancoymycin
- Teicoplanin
What should empirical antibiotics be adjusted on the basis of?
Culture results
What is the problem with determining suitable antibiotics from culture results in febrile neutropenia?
Cultures are often negative
What should be done if there is no response to antibiotics after 36-48 hours in febrile neutropenia?
- Antibiotics should be reviewed with microbiological advice
- Anti-fungal cover should be considered
What does recombinant human granulocyte-colony stimulating factor (G-CSF) do?
Stimulates the production of neutrophils in the bone marrow
How is G-CSF administered?
SC
What is the purpose of G-CSF?
It may reduce the duration of chemotherapy-induced neutropenia, and thereby reduce the incidence of associated sepsis
Does G-CSF improve survival?
Currently no evidence that it improves survival
Can G-CSF be used prophylactically?
In some cases, but not routinely
Give an example of when G-CSF might be used prophylactically in some cases?
Following chemotherapy
When can G-CSF be used in an established infection?
Can be given alongside antibiotics to counteract infection
What is the mortality from febrile neutropenia in people with solid tumours?
5%
What is the mortality from febrile neutropenia in people with haematological malignancies?
11%
What does successful management of febrile neutropenia depend on?
Early recognition
How can early recognition of febrile neutropenia be achieved?
- Patients should be educated to monitor their symptoms, including body temperature
- Should be given clear, written instructions on when and how to contact appropriate services in the event of concerns
