24 - Febrile Neutropenia Flashcards
Empiric Antibiotic Treatment
PCN ALLERGY
Step 2: Febrile Neutropenia
Ciprofloxacin** + **Clindamycin
OR
Aztreonam** + **Vancomycin
instead of:
Cefepime / Meropenem / Imi-Cilastatin / Pip-Tazo
STEP 1
- *5 Step Treatment Approach**
- *FEBRILE NEUTROPENIA**
WITHIN 15 MINUTES
A) Assume Bacterial infection
fever is often the ONLY sign of infection
B) **C**ollect SAMPLES
- *CBC + Leukocyte Differential Count** = ANC
- *>** 2 sets of Blood Cultures
C) Perform Systemic patient Assessment
maximize chances of determining SITE of infxn / organism
Febrile Neutropenia PROPHYLAXIS
What to give if….
Allogenic Hematopoeietic Cell Transplant = HSCT?
AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN
AntiVIRAL
NOPE, only if seropositive for HSV or VZV
AntiFUNGAL
FLUCONAZOLE
CANDIDA - HSCT
Why does NEUTROPENIA indicate
Infection Risk?
Neutrophils
Innate Defense –> target Bacteria & fungi
↓Neutrophils –> INCREASING INFECTION RISK
OUTPATIENT TREATMENT
PCN ALLERGY
Step 5b: Reassess Therapy for Outpatient
Febrile Neutropenia
Goal: Defervesence within 3 days of ABx infection
if failure –> RE-ADMIT to hospital
CIPROFLOXACIN** or **LEVOFLOXACIN
+
CLINDAMYCIN
instead of Augmentin
STEP 5
- *5 Step Treatment Approach**
- *FEBRILE NEUTROPENIA**
Step 5
Reassess Therapy & MODIFY if necessary
Various Situations:
Dependent on clinical & microbiologic Data
Duration of Treatment:
Afebrile >2 days & ANC has recovered (> 500)
STEP 3
- *5 Step Treatment Approach**
- *FEBRILE NEUTROPENIA**
Step 3: ANC CALCULATION
Absolute Neutrophil Count (ANC) < 500 cells/mm3
Mature: PMN or SEGs // Immature: BANDS
Percent:
Total WBC x (%PMN/100 + %BANDS/100)
Total Number:
(PMNs + Bands) x 1,000
When to use
PROPHYLAXIS
for
Febrile Neutropenia
High Risk = Severe PROLONGED neutropenia
Predicted to have ANC < 100 cells/mm for > 7 days
Examples:
- *HSCT**
- *Allogenic Hemtopoietic Cell Transplant**
INDUCTION CHEMOTHERAPY
for Acute Leukemia
What to do if….
Identifiable cause of Fever
Ex. Pneumonia
- *Step 5a: Reassess Therapy for INPATIENT**
- *Febrile Neutropenia**
Identifiable cause of Fever
Ex. Pneumonia
VVVV
ALTER TREATMENT for SPECIFIC INFXN
What to do if….
Persistant fever > 4 DAYS
AFTER
Broadening Spectrum ABx / no Identified source
- *Step 5a: Reassess Therapy for INPATIENT**
- *Febrile Neutropenia**
Persistant fever > 4 DAYS
AFTER
Broadening Spectrum ABx / no Identified source
VVVV
ADD:
EMPIRIC ANTIFUNGAL THERAPY
Ex:
Cefepime + Amphotericin B
Empiric Antibiotic Treatment
Step 2: Febrile Neutropenia
1 Anti-Pseudomonal B-Lactam
C-MIP
CEFEPIME
Meropenem - Imipenem/Cilastatin
(ESBL Suspected)
- *Pip/Tazo**
- do not use WITH VANCO*
STEP 2
- *5 Step Treatment Approach**
- *FEBRILE NEUTROPENIA**
2 - Select Empiric Antimicrobial Therapy
Recommendation:
- *ALL PATIENTS** should recieve an INITIAL IV DOSE
- *ASAP = within 1 hour**
Most common infection = translocation across intestine
20-30% bacteremia
Goal is to Cover:
MOST COMMON (Gram POS) & MOST VIRULENT (Gram NEG)
OUTPATIENT TREATMENT
Step 5b: Reassess Therapy for Outpatient
Febrile Neutropenia
Goal: Defervesence within 3 days of ABx infection
if failure –> RE-ADMIT to hospital
CIPROFLOXACIN** or **LEVOFLOXACIN
+
AUGMENTIN
amoxicillin/clavulanate
Febrile Neutropenia PROPHYLAXIS
What to give if….
INDUCTION CHEMOTHERAPY for Acute Leukemia?
&
SEROPOSITIVE for HSV +/- VZV
AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN
AntiVIRAL
ACYCLOVIR or VALACYCLOVIR
+ Annual Flu Shot
AntiFUNGAL
POSACONAZOLE or VORICONAZOLE
for Candida +/- Aspergillus
What to do if….
PERSISTANT FEVER** + **HEMODYNAMICALLY UNSTABLE
Ex.
Fever > 3 days + BP dropping significantly
- *Step 5a: Reassess Therapy for INPATIENT**
- *Febrile Neutropenia**
PERSISTANT FEVER + HEMODYNAMICALLY UNSTABLE
Ex.
Fever > 3 days + BP dropping significantly
VVVV
BROADEN EMPERIC THERAPY
for RESISTANT - Gram +/- & Anaerobes
Ex.
MEROPENEM (for ESBL) + VANCOMYCIN
STEP 4
- *5 Step Treatment Approach**
- *FEBRILE NEUTROPENIA**
Step 4:
ID Candidates for OUTPATIENT Treatment
Carefully selected patients that are at:
low risk for medical complications –> ORAL ABx
What to do if….
Febrile for 2 days + Negative Cultures
- *Step 5a: Reassess Therapy for INPATIENT**
- *Febrile Neutropenia**
Febrile for 2 days + Negative Cultures
AND
ANC > 500
VVV
MAY DISCONTINUE THERAPY
What to do if….
PERSISTANT FEVER
but, stable & no site of infxn detected
- *Step 5a: Reassess Therapy for INPATIENT**
- *Febrile Neutropenia**
PERSISTANT FEVER
but, stable & no site of infxn detected
VVV
CONTINUE THERAPY** until **ANC > 500
+
keep looking for infxn source
Febrile Neutropenia
DEFINITION
FEVER
Single reading > 38.3*C (101*F)
or a > 38*C sustained over an hour
- *SEVERE NEUTROPENIA**
- *ANC < 500 cells/mm3**
Seen:
CHEMOTHERAPY START** within **6 WEEKS
Febrile Neutropenia PROPHYLAXIS
What to give if….
Allogenic Hematopoeietic Cell Transplant = HSCT?
&
SEROPOSITIVE for HSV +/- VZV
AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN
AntiVIRAL
ACYCLOVIR or VALACYCLOVIR
+ Annual Flu Shot
AntiFUNGAL
FLUCONAZOLE
for CANDIDA - HSCT
When to add VANCOMYCIN?
Step 2: Empiric ABx Therapy
Febrile Neutropenia
HIGH RISK PATIENTS
SEPTIC (hemodynamically Unstable) = ↑Mortality risk
Suspected:
PNEUMONIA
CRSBI (Catheter related infxn)
Skin or Soft-Tissue Infxn
H/o MRSA infxn or colonization
- Addition of VANC (for gram POS) is NOT associated w/ clinical benefit & may promote RESISTANCE
- DO NOT USE PIP/TAZO w/ VANCOMYCIN**
Febrile Neutropenia PROPHYLAXIS
What to give if….
INDUCTION CHEMOTHERAPY for Acute Leukemia?
AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN
AntiVIRAL
NOPE, only if seropositive for HSV or VZV
AntiFUNGAL
POSACONAZOLE or VORICONAZOLE
Candida +/- Aspergillus
beware of chemotherapy drug interactions
