Febrile Neutropenia Flashcards
Define febrile neutropenia
Fever and absolute neutrophil count (ANC) of less than 0.5x10^9/L following cytotoxic chemotherapy or hematopoietic stem cell transplant.
Febrile neutropenia is a serious complication of cancer treatment (clinical emergency).
Why must we act quickly when a patient develops febrile neutropenia?
Febrile neutropenia is a clinical emergency! We must act quickly to avoid organ dysfunction and sepsis.
Why do we never take rectal temperatures on patients being treated for cancer?
There is a risk of minor trauma to the rectum when inserting the thermometer. Such an injury could create an easy point of entry into the bloodstream for bacteria naturally living in the colon, which is dangerous for immunosuppressed cancer patients.
What is the preferred way to obtain a cancer patient’s temperature?
What temperature do we consider to be a fever?
Oral temperatures are preferred.
Fever: Oral temp of 38.3 or more on one occasion OR oral temp of 38.0 or more for 1 hour or more
Name 3 reasons why neutrophils are so important
- They are the most abundant immune cell (60-70% of all leukocytes)
- They act as first responders of the innate immune system.
- They clear bacteria, fungi and mycobacterium through phagocytosis
How common is fever in neutropenic oncology/SCT patients?
Fever occurs in 1/3 of these patients
Comorbidities associated with mortality in febrile neutropenia cases (4)
Sepsis
Meningitis
Pneumonia
Mycosis
What is functional neutropenia?
Certain hematological malignancies impede phagocytosis and killing of pathogens even if the ANC is normal.
Name some risk factors for serious infections in patients undergoing cancer treatment
- Chemotherapy-induced neutropenia
- Functional neutropenia
- Central venous catheter
- Breakdown of skin and mucosal barriers (ulcers)
If neutropenia is predicted to last more than 7 days, cancer patients are at risk of…
having altered humoral and cellular immunity
Do all neutropenic patients develop fever when they have a serious infection?
NO. Patients may be afebrile and neutropenic with signs of infection or deterioration (hypothermia, hypotension, listlessness, confusion, etc.)
How can chemotherapeutic drugs directly cause infections?
Chemotherapeutic agents damage the oral and GI epithelium. Bacteria and fungi will enter the bloodstream through the injured mucosa.
How can indwelling catheters directly cause infections?
They predispose to bacteremia (presence of bacteria in bloodstream) from skin flora.
4 infectious causes of fever (organisms) in cancer patients
- Gram negative bacteria
- Gram positive bacteria
- Fungi
- Viruses
5 non-infectious causes of fever in cancer patients
- Drug-related (penicillin)
- Malignancy-related (malignant cells release cytokines)
- Thrombosis (clots)
- Transfusion reaction
- Hemophagocytic lymphohistiocytosis
Vital signs: When should we be worried the patient with febrile neutropenia is undergoing septic shock?
- Wide pulse pressure
- Tachycardia disproportionate to fever
Worrying vital signs in febrile neutropenia (3)
- Wide pulse pressure
- Disproportionate tachycardia
- Hypoxia (<94%)
What is important about physical examination in febrile neutropenia?
Full exam is imperative, including a thorough review of skin, catheter site, perineum (genitals), toes.
Note that the degree of inflammation and erythema may be blunted by the lack of neutrophils
Key investigations for febrile neutropenia
Blood culture, CBC, urine culture, liver enzymes, etc
Which patients are considered high risk (febrile neutropenia)?
- Patients with profound neutropenia (ANC<0.1x10^9)/L with predicted neutropenia for >7days)
- Significantly comorbid patients
- Patients with obvious infection
- Patients with trisomy 21
- Patients with AML, ALL or Burkitt’s
- Patients <60 days post HSCT or with graft-vs-host disease
- Patients with aplastic anemia
- Patients with solid tumours with active marrow involvement (metastases)
3 cancers that put patients at high risk if they develop febrile neutropenia
- Acute myeloid lymphoma (AML)
- Acute lymphoblastic leukemia (ALL)
- Burkitt’s leukemia/lymphoma
These diseases require very intense chemotherapy so we do not expect their immune systems to recover any time soon.
What febrile neutropenia patients are considered low risk?
- Anticipated duration of neutropenia <7days
- No comorbidities
- Patients with adequate liver and kidney function
- Patients in stable clinical condition
How are low risk patients treated?
They can consider outpatient therapy (ceftriaxone + tobramycin followed by oral antibiotics)
How do we treat patients with febrile neutropenia (empiric management)?
Broad-spectrum antibiotics
