neutropenic fever Flashcards
define febrile neutropenia
sustained fever off over 38.3 C with a neutrophil count of less than 500 cells/ml or expected to decrease to that level within the next 48 hours
most common organisms associated with febrile neutropenia
gram positive organisms
what investigations should be performed in suspected neutropenic fever include
Two blood cultures taken simultaneously form 2 peripheral venepunctures or one peripheral and any central venous access
radiological diagnostic must also bee applied based on the suspected site of infection
respiratory signs ? chest x-ray or CT
what is used to asses the risk index in neutropenic fever
MASCC score
anything above 21 are at low risk of complications whilst anything above 21 is at high risk of complications
what is the management of neutropenic fever
1- after identification of a fever on 2 readings of higher than 38.4 and an ANC of 500 or less
2- MASCC score should bee calculated ( over 21 is considered high risk )
3- high risk patients should be admitted to the hospital and started on IV antibiotics
4- low risk patients ( MASCC score of less than 21) should be discharged to outpatient and sent with an oral antibiotic
who are the low risk patients ?
have a score of under 21 on the MASCC scoring system
have neutropenia that is expected to resolve within 7 days
usually associated with patients that have solid tumors
what are the indications regarding antibiotic use in low risk patients
oral quinolone to be avoided if quinolone was previously taken as prophylaxis
who are the high risk patients
those with a MASCC score of less than 21
neutropenia of less than 100 and not expected to resolve within 7 days
presence of comorbidities
evidence of hepatic or renal impairment
in cases of high risk neutropenic fever -standard treatment for gram negative bacteria and MRSA ?
carbapenem
cephalosporin
in cases of high risk neutropenic fever - clinically unstable/septic shock/ respiratory distress/ Hx of pseudomans infection
anti pseudomonal beta lactam along with an aminoglycoside
in cases of high risk neutropenic fever
gram positive/ catheter related infections / resistant to penicillin/ hypotension or shock
vancomycin
teicoplanin is an alternative
in cases of high risk neutropenic fever - vancomycin resistant infection
linezolid
how can catheter related bacteremia be confirmed or highly suspected ?
blood must be cultured from both thee catheter and peripherally to measure DTTP
DTTP of more than 2 hours is highly indicative of catheter related bacteraemia
if pneumonia, pneumocystis infection or cellulitis is diagnosed on clinical grounds ?
pneumonia - adding a macrolide to a beta lactam antibiotic
pneumocystis infection - high dose co-trimoxazole
cellulitis - add vancomycin
management in clinical or microbiological evidence of intra-abdominal or pelvic sepsis
add metronidazole
assessment for clostridium is necessary
management in cases of vesicular lesions or suspected viral infections
therapy with acyclovir
ganciclovir only to be used in high suspicion of CMV
management in suspected meningitis or encephalitis ?
lumbar puncture is mandatory
bacterial meningitis - ceftazidime + ampicillin
viral encephalitis - acyclovir
which patients are at risk of candidiasis ?
prolonged neutropenia
those with haematological malignancies undergoing myeloablative therapy
when is treatment of candidiasis indicated and what is the treatment of candidiasis in neutropenic fever ?
indication : empirical treatment in patients whose fever fail to respond to broad spectrum antibiotics after 3-7 days
already exposed to an azole ?
give liposomal amphotericin B or caspofungin
low risk of invasive aspergillosis ?
fluconazole
role of GCSF
granulocyte colony stimulating factor
should be used in high risk patients
recommended in moderate risk
not used in low risk patients
when should MGF be used ?
in cases of radiation induced myelosuppression
how should GCSF be used ?
if received it as prophylaxis then continue until recovery
if received long acting - nothing more
didn’t receive prophylaxis ? daily GCSF until normal count
no high risk features ? no need for GCSF
when should follow up for neutropenic fever patients bee
48 hours after initiation of treatment
what is the next best step in mngmnt after 48 hours of therapy and fever has improved and ANC has risen above 500
identify if thee patient is low or high risk first
low risk - continue oral ab and early dischargee
high risk - if there is an identified pathogen give specific ab therapy
no pathogen then discontinue aminoglycosidde and continue IIV therapy
what is the best next step in mngmnt of a patient that still has a fever after 48 hours of therapy
asses if the patient is stable or not first
stable ? continue therapy
unstable - hospital admission
