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Block 4 - Heamatology > Lecture 17 - Approach To Infective Fever > Flashcards

Lecture 17 - Approach To Infective Fever Flashcards

1
Q

Discomfort due to fever: for each 1degree celcius elevation of body temp

A
  • metabolic rate increases 10-15%
  • insensible water loss increases 300-500ml/m2/day
  • o2 consumption icnrased by 13%
  • heart rate increases 10-15/min
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2
Q

Antipyretic management

A
  • paracetamol usually first line used - well toletared with minimal side effects
  • adult: 1000mg q 4h
  • can be hepatotoxic in high doses, can upset stomach
  • restrict to a maximum of 4g/day
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3
Q

Associated symptoms of fever

A
  • shaking chills
  • ear pain, ear drainage, hearing loss
  • visual and eye symptoms
  • sore throat
  • abdominal symptoms
  • back pain, joint, skeletal pain
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4
Q

Physical exam for fever

A
  • vital signs
  • neurological exam
  • skin lesion, mucous membrane
  • eyes
  • ENT
  • lymphadenopathy
  • lungs/heart
  • abdominal region:
  • MSK
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5
Q

Lab exam

A
  • FBC
  • EUC
  • LFT
  • ESR
  • CRP
  • Urinalysis
  • blood, urine
  • skin test: TB
  • serology
  • ANA
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6
Q

Imaging

A
  • CXR
  • ultrasonography
  • radiographic contrast study
  • radionuclide scan
  • CT/MRI
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7
Q

Invasive proceduress

A
  • Bone marrow
  • skin lesion
  • lymph node
  • liver
  • temporal artery
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8
Q

Indication for hospitalisation

A
  • patients who are clinically unstable or at risk for rapid deterioration
  • major alterations of immunity
  • need for IV antimicrobials or orhter fludis
  • advanced age
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9
Q

Causes of Pyrexia of unknown cause (PUO)

A
  • infection: half
  • neoplasm
  • non-infectious inflammatory disease
  • miscellaneous cause
  • undiagnosed
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10
Q

Infections commonly associated with PUO

A
  • localized pyogenic infection
  • systemic bacterial infection: TB
  • fungal infection
  • intravascular infection for patients with catheters
  • viral infection
  • parasitic infection
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11
Q

Malignancies commonly associated with PUO

A
  • hodgkins disease
  • NHL
  • Leulkemia
  • renal cell carcinoma
  • hepatoma
  • Colon carcinoma
  • Atrial myxoma
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12
Q

Non-infectious inflammatory diseases with PUO

A
  • collagen vascular/hypersensitivity diseases: lupus, still’s disease, termporal arteritis
  • Granulomatous disease: Crohn’s disease, sarcoidosis, idiopathic granulomatous disease
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13
Q

Misclellaneous causes of PUO

A
  • drug fever
  • factictious fever
  • Familial mediterranean fever
  • recurrent pulmonary emboli
  • subacute thyroiditis
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14
Q

Drug fever

A
  • contamination of the drug with a pyrogen or MO
  • pharmacologic action of the drug itself
  • allergic reaction to drug
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15
Q

Immunocompromised host

A
  • neutropenia: leukemia therapy, BMT, myelofibrosis, cyclophosphamide, alcoholism -> Staph, E Coli, klebsiella, pseudomonas, enterococci, candida
  • T cell suppression: leukemia, lymphoma, transplant, AIDS, steroids, Cyclosporin A -> Herpes, TB, legionella, nocardia, cryptococcus, pneumocystis
  • Illness related: CLL, myeloma, splenectomy -> pneumococcus, neisseria, mycoplasma, enterovirus, Giardia
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16
Q

Definition of fever in febrile neutropenia

A
  • Single oral temp >38.3
  • temperature of >38 on two occsions separated by 1 hour
  • if temp is between 37-38, repeat termp in 1 hour to see if the above criteria for treatment are met
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17
Q

Definition of neutropenic sepsis

A
  • Hypotension and/or tachycardia in the presence of a neutrophil count less than 1x10^9 and infection
  • patients with neutropenic sepsis will not necessarily have a fever
  • patients with neutropenic sepsis have a high mortality without prompt appropriate treatment
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18
Q

DEfinition of neutropenia in febrile neutropenia

A
  • Absolute neutrophil count
19
Q

Neutropenia

A
  • normal ANC: 2

- neutropenia: ANC

20
Q

When does neutropenia occur

A
  • most chemotherapy agents/protocols cause neutropenia nadir at 10-14 days
  • but can see anytime from a few days after chemotherapy to up to 4-6 weeks later depending on agents used
21
Q

Epidemiology

A
  • more than 60% febrile neutropenia episodes are due to infection
  • 20% of patients with ANC
22
Q

Duration of neutropenia and risk

A
  • 14 days: high risk
23
Q

Common microbes

A
  • Gram +: staph aureaus, staph epidermidis, E faecalis, Corynecacterium
  • Gram -: e.coli, klebiella, pseudomonas aeruginosa
  • Fungi: candia, aspergillus
24
Q

Splenectomy: think what organisms?

A
  • strep pneumonia
  • neisseria meningitidis
  • H. Influenzae
25
Q

Splenectomy/hyposplenism carries an increased risk of overwhelming sepsis

A
  • Sickle cell disease, Coeliac disease
  • GvHD
  • ITP
  • splenic irradiation
  • surgical removal
26
Q

Caused of infection after splenectomy

A
  • strep pneumonia
  • H.influenza
  • Meningococcus
  • Salmonella spp
  • Dog butes
  • Babesia microti
  • p. Malaria
27
Q

Preventative measures

A
  • vaccinate before splenectomy with: pneumococcal, meningococcal, H. Influenza
  • penicillin prophylaxis
  • early empirical therapy
  • alert bracelet
28
Q

Examination

A
  • be prepared to find no signs of inflammation
  • look in mouth: periodontium, pharynx
  • lungs
  • abnomen for tenderness - RLQ
  • perineum, including anus (no rectal exam)
29
Q

Skin exam

A
  • ask for tenderness
  • bone marrow aspiration sites
  • vascular catheter access sites
  • and tissues around nailes
  • rashes
30
Q

Investigations

A
  • FBC
  • biochemistry
  • microbiology
  • radiology
31
Q

Lumbar puncture

A
  • should be considered if a CNS infection is suspected and thrombocytopenia is absent or manageable
32
Q

Skin lesion

A
  • aspiration or biopsy of skin lesion suspected of being infectes should be performed for cytologic testing, gram staining, culture
33
Q
  • Imaging
A
  • CXR,
  • high resolutoin CT chest only if persistent fevers with pulmonary symptoms after initiation of empiric Abx
  • CTA if suspect PE
  • CT for abdomen for necrotizing enterocolitis or typhilitis
34
Q

Oral antibiotics

A
  • for patients who are low risk for developing infection-related complications during neutropenia
  • oral ciprofloxaxin plus amoxicillin/clavulanate
  • oral ciprofloxacin plus clindamycin for penicillin allergy
  • this is rare: most patient will receive IV antibiotics
35
Q
  • if inpatient and high risk
A
  • empiric antimicrobial therapy after blood cultures

- must be initiated within 1 hour

36
Q
  • 3 approached for IV empiric therapy
A
  • IV mono therapy
  • IV dual therapy
  • combination therapy: mono or dual therapy + vancomycin
37
Q

When temp does not go away

A
  • non-bacterial infection
  • bacterial resistance to first line therapy
  • slow response to drug in use
  • super infection
  • inadequate dose
  • drug fever
  • cell wall deficient bacteria
  • infection at an avascular site
  • disease-related fever
38
Q

Antifungals

A
  • easy to initiate, difficult to stop
  • pulmonary aspergillosis/Sinusitis, Hepatic candidiasis
  • CT chest and abdomen
  • CT sinuses
  • cultures of suspicious skin lesions
39
Q

Antifungals

A
  • voriconazole or amphotericin for high risk option
  • fluconazole: only candida
  • itraconazole
  • echinocandins
40
Q

Infective fevers in transplantation

A
  • Bone marrow or peripheral transplant
  • solid organ transplant
  • other tissue transplant
41
Q

BM and PBSC transplantation: why does infection occur

A
  • disease itself may be a risk of infection
  • patient needs to be immunosuppressed before transplant
  • prolonged period of neutropenia
  • GvHD
  • general support measured complicated by infectin
42
Q

Risk period for infection after transplantation

A
  • neutropenic phase: generally 3 weeks
  • 1-3 months: acute immunosuppresion
  • 4-12 months: chronic immunosuppression
43
Q

Further infectious complications: days 30-100

A
  • pneumonia: interstitial
  • bacterial sepsis with prolonged neutropenia
  • fungaemia, dissemination, chronic hepatic candidiasis
  • reactivation of latent virus: CMV, BK

Block 4 - Heamatology (23 decks)

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