Neutropenic Fever Flashcards
What is the definition of neutropenic fever
Fever in the setting of cancer and active chemotherapy
What is the most common etiology of neutropenic fever (broad not specific), and why?
Usually caused by colonizing bacteria or yeast of the GI tract because the chemo disrupts mucous membranes of mouth and GI tract allowing for organisms to enter
What is the earliest symptom of infection for neutropenic fever
fever
What temps are actually considered a fever
Single temp measured at _>_38.3 C OR 101F
or
_>_38.0 C (100.4) sustained over one hour period
What is the cut off of ANC for neutropenic fever
ANC of <500 cells/microL or an ANC that is expected to decrease to <500 cell/microL within 48 hours
What is functional neutropenia
When a pt has >500/microL but because of a hematological malignancy that impacts fxn of cells they are at higher risk of infection
How do you calculate the ANC
Total WBC x (%PMNs + %bands)
What is considered a low risk neutropenic fever pt
-Expected to be neutropenic for <7 days
No comorbities (like renal or liver dysfunction)
Solid tumor chemo regimen
What is considered high risk for pts with neutropenic fever
Neutropenia expected >7 days
Ongoing comorbities
Hematologic cancers (especially leukemias)
WHat is the MASCC score
Multinational association of supportive care in cancer
What is the max MASCC score
26
What mask score is considered high risk
<21 is high risk (the lower the number the higher the risk)
Ask if we need to know the scores by heart or not- screen shot on back of this card
What are the most common causative organisms of neutropenic fever
GNR- particularly pseudo
GPC- particularly S epi
MRSA sometimes
Candida/aspergillus
Herpes/Herpes zoster/CMV
What are the three different presentations of neutropenic fever (in order of easiest to hardest to treat)
- Microbiologically documented infxn- culture is positive
- Clinically documented infection that is not cultured (ex: cellulitis)
- Unexplained fever with no clinical focus or positive culture
What are the important things to look for when taking a pt hx with neutropenic fever
Probing for risk factors/ signs and sx of source of infxn
Finding out what organism a pt had in a previous infxn
Ask about non-infectious causes like recent transfusions
Ask about comorbidities (risk stratification)
What is the most common site of infxn in neutropenic fever
Lungs
What sites should be examined if a pt has neutropenic fever
Lungs
Indwelling catheters/ports/IVs
Skin and mucous membranes
Perianal exam (but DO NOT PERFORM DRT)
What labs should be performed in a pt with neutropenic fever
BC
CBC
CMP
UA with Culture
Sputum Culture (if productive cough)
Stool Culture with C. diff testing if diarrhea is present
CSF testing if there is any HA or nuchal rigidity
What are the imaging modalities used when a pt has neutropenic fever
CXR in low risk (since lung is most common spot)
CT scan of chest in high risk pts
CT of whatever site is suspicious for infxn
What is always an emergency in neutropenic pts
a fever
What is the first step for tx of neutropenic fever
Immediately starting Abx (within one hour of fever onset- but after collecting BC if at all possible)
How often is bacteremia present in neutropenic fever pts
10-25% of the time
Is neutropenic fever more common in blood cancers or solid tumors
Blood cancers
What are the empiric txs for high risk pts with neutropenic fever
- Ceftazidime 2G IV q8hr
- Cefepime 2GIV q12h
- Pip/Tazo 4.5G IV q6h
-Imipenem 500mg IV q6h
-Meropenem 1G IV q8h
bolded= for more resistant organism susp.
What are the empiric tx for low risk pts with neutropenic fever
Cipro 500mg po bid
OR
Levo 750mg po bid
AND
Amox/Clav 500/125 mg po TID
When would you cover for GPC in a high risk pt with neutropenic fever
If the pt is hemodynamically unstable or has evidence of severe sepsis
Pneumonia documented
Pos BC for GPC
Catheter related infxn (chills post infusion)
Skin or soft tissue infxn
Colonization with MRSA
Severe mucositis
How long do you tx pts with neturopenic fever with abx
until the pts ANC is >500 (and some physicians continue abx for 24-48 hours after)
When are fluoroquinolones used to prophylax pts
if a pt is expected to have a prolonged or profound neutropenia (like bone marrow transplant pts)
Do you prophylax for GP organisms
no
When do you prophylax for candidal infxn
When a pt is undergoing HSCT or induction for acute leukemia
When do you prophylax for aspergillus in pts
age 13 and over undergoing intensive chemo for AML/MDS
What is used to prophylax for aspergillus
posaconazole
Do you prophylax pts undergoing tx for solid tumors
no
When are hematopoietic growth factors given to pts
When a pt has anticipated risk of fever and neutropenia is 20% or greater
-Not considered normally if a pt already has febrile neutropenia
