Mar26 M1-Febrile Neutropenia Flashcards
febrile neutropenia occurs in what patients usually
cancer pts on chemo
pathophysiology of febneut
- chemo and anti-cancer drugs damaging to rapidly proliferating cell lines (BM, GIT)
- GIT mucosa acting as bacteria barrier is impaired = bacteria and fungi get in blood
- low neutrophils (needed to fight infection) bc of drop of cell prod in BM
only sign of inflammation in pt on chemo with febneut
fever. no pus, inflam response is diminished bc low neutrophils
treatment of feb neut
-empiric systemic Abx immediately
febneut = medical emergency
how helpful physical exam is to find cause of fever in febneut
not helpful, often won’t find cause of fever on physical exam
how neutrophils drop with time in feb neut and with every chemo round
drop until reach a naiter point (lowest point) (bc every chemo round has an element of BM suppression)
when Abx stopped in febneut
once neutrophils over 500 for 2 consecutive days
definition of febrile neutropenia
- oral temp over 38.3 (or between 38 and 38.2 for an hour)
axillary = add 0.5
don’t do rectal in neutropenic
neutropenia definition
- lower than the normal 1.8 to 7.5
- usually use <1.5
- severe = less than 500
- myelodysplastic syndrome (normal nbr but abnormal fct) = neutropenia too
pathogenesis of febneut: what chemo does
- mucositis (radiation and chemo cause DNA damage and release of inflam cytokines)
- often oral mucositis = consider it’s in whole GIT
type of bacteria we’re afraid of in febneut (we don’t want them to be in circulation)
gram negatives
causes of febneut other than the chemotherapy
immune defects in general
- (anti cancer tx attakc BM)
- myelodysplastic syndromes
- splenectomy
- CLL
- immunosuppression (glucocorticoids, HIV)
3 types of risk factors for complications in febneut
- patient related predictors (>65, poor feeding, active comorbidities)
- disease related predictors (advance stage of cancer, BM failure bc marrow involved)
- anti-cancer tx related predictors (high dose chemo, absence of GF support)
risk stratification in febneut patients: how it’s done
- high risk = expected to have <100 for over 7 days. will include neut<500, IV Abx, often prolonged. + include pt with transplant or AML
- low risk = anc (absolute neutrophil count) < 500 expected for less than 7 days + no other problems. can receive Abx as outpatient + include pt with solid tumor
infectious vs non-infectious causes os febneut + when give Abx
- infectious = often endogenous bacteria from gut flora
- non-infectious = drug, transfusion rx, rash, underlying cancer
- ALWAYS give Abx
most common pathogens seen today as cause of febneut
- G+ bacteria
- MOST COMMON IS STAPH EPIDERMIS: very virulent
some common cultured organisms in febneut
-G- like pseudomonas, e.coli
-G+ like staph epidermis, staph
aureus
-fungi
-herpes
when to consider fungi as cause of febneut
- persistent fever or fever that stops and comes back + neutrophils that are low for over 2 weeks
- *fever that respikes = treat for fungi
viruses that reactivate in febneut
- HSV
- HSZ
- CMV, EBV, HHV-8
- respiratory viruses (infleunza, RSV, adenovirus, metapneumovirus)
steps when see pt with febneut
- vitals
- IV access
- draw blood to check neutropenia
- CBC, fever, status, electrolytes
- blood cultures
- Abx
- CXR and other
things to check on physical exam (the important stuff)
- check impaired mental status (may indicate sepsis and incoming shock)
- vitals
- infected mucosas = sinuses, mucous membranes, gingiva, teeth, lungs, abdoment (bloating, tenderness, perit signs, hemorrhoids)
- no rectal exam*
typical physical exam sign in G- infections like pseudomonas
primary ecthyma gangrenosum (erythema + dark center)
medication to avoid in febneut
tylenol or NSAIDs (because masks the fever and then no way of following disease)
main management goals in febneut
- empiric Abx (cover the most virulent pathogens like G- pseudomonas)
- always cover most virulent even if see signs of G+ for ex (like skin lesions)
- start Abx immediately
high risk patients management
- initiate monotherapy with anti-pseudomonal beta lactam Abx
- meropenem and piperacillin-tazobactam
- anti-fungals at 4 days if cause of fever not found
- NO G+ coverage initially (only if sepsis, pneumonia, bad CV disease, etc.)
- anaerobic coverage only if sinusitis, periodontal cellulitis, necrotizing mucositis, etc.
most common G+ organisms Abx
vancomycin
most common anaerobes coverage Abx
metronidazole (Flagyl)
when to stop febneut therapy
ANC>500 + afebrile, all that for 2 days
low risk pts management
- IV Abx as outpatient and stay close
- readmit if fever worsens, persists, new symptoms and signs of infection
normal regimen for low risk pts in febneut
- ciproflaxin (fluoroquinolone = broad spectrum + only p.o. against pseudomonas)
- clavulin (beta-lactam = G+, G-, anaeorbes, NOT pseudomonas)
