W2P3 Flashcards
Febrile Neutropenia
- diagnostic temperature
PLUS what?
Fever ≥ 38.3 oC oral in a single measurement ≥ 38 oC in two measurements within 1 hour PLUS Low absolute neutrophil count (ANC) ≤ 500 cells/μL
Could be axillary or oral NEVER RECTAL for people who have cancer/ have low neutrophils
Who gets Febrile Neutropenia
- *Cancer patients get fever
- Up to 50% in solid tumour cancers
- More than 80% with hematologic cancers
Usually after a week after their last chemotherapy (nadir of ANC)
Less than half have a documented infection
PHYSICAL EXAM and CLINICAL SUSPICION are key
Protocols exist in order to not miss things
What should you think of for Neutropenia
Secondary to Cancer Chemotherapy
- Think of denuded gut secondary to chemotherapy
- Including mucositis
- Usually Gram negative enteric rods - Think of central line infections
- Usually Gram positive cocci (CoNS, MSSA/MRSA)
- Pseudomonas aeruginosa - Think of fungal organisms
- Candida spp (from gut, from central line(s))
- Aspergillus spp (from lungs) - Finally, think of common organisms causing fever
- S. pneumoniae, respiratory viruses, C. difficile
What should you think of with Fever in Cancer Patients In the absence of obvious symptoms
- Think first of bacteria coming from a denuded gut
SO CHEMOTHERAPY IS KEY
- Please note: Fever in a NEWLY diagnosed cancer patient (no chemotherapy yet) is due to either the tumour/cancer or community stuff (eg. S. pneumoniae, respiratory viruses etc) - Then think of community acquired sources
- Pneumonia
- Respiratory viruses
If persistent fever: especially while on very extensive and broad spectrum antibiotics, THEN think of fungal illness
Candida spp, Aspergillus spp
What should you think of with Fever in Cancer Patients With specific symptoms
Think of central line sepsis especially if IV site is red and/or painful
MOST COMMON CAUSE OF BACTEREMIA IN CANCER CHEMOTHERAPY PATIENTS = CoNS
If diarrhea: think of C. difficile
What to think of with Fever in Cancer Patients With symptoms of mucositis and/or shock
Think of all of the above AND:
Streptococcus viridans
This relatively benign respiratory tract organism has been increasingly associated with shock and ARDS in cancer patients on chemotherapy
Risk factors include:
“strong” chemotherapy which may lead to mucositis
High dose Ara-C
recall these are IMMUNE SUPPRESSED PATIENTS so commensal organisms are dangerous in this group
What are the Empiric Antibiotic Choices for Fever in Cancer Patients
Overall at minimum must cover all of the following:
- Bacteria from the gut (including anaerobes)
- Pseudomonas spp
- Staphylococcus aureus
IF there is the presence of mucositis or shock, must cover Streptococcus viridans also
IF you know or suspect resistance, what organisms should you think of?
MRSA, ESBL, VRE
Empiric Therapy for NEWLY diagnosed patient coming in with fever
Any antibiotic that covers community organisms causing pneumonia, and sepsis
e.g. Ceftriaxone IV
+/- “atypical” organism coverage
If signs of viral illness
Oseltamivir?
Acyclovir?
Empiric Therapy
KNOWN cancer patient coming in with febrile neutropenia
Broad spectrum beta-lactams \+/- aminoglycosides IV \+/- vancomycin IV depending on clinical condition Line sepsis Septic shock Known MRSA colonization Sometimes oral therapy is used eg. Ciprofloxacin + Clindamycin
What should you think of in: Fever that persists with neutropenia, on broad spectrum AB
THINK FUNGAL INFECTION
- give empiric antifungal treatment
Fever in cancer patients Empiric antifungal treatment?
Usually not given empirically IN THE BEGINNING unless there is clinical evidence for a fungal infection:
- Characteristic rash
- Lung nodules on CXR
- Positive blood culture for yeast or fungus.
A minority of patients (~4%) will have invasive fungal disease
KEY: Antifungals are started if fever persists past 4 days in cancer patients with febrile neutropenia
Or sooner as needed (clinical and/or lab evidence)
Once you think of fungal infection, what else should you recommend (investigations)
Need to see where the supposed Candida spp has caused disease:
Need liver and spleen imaging
Need retinal exam
Chest CT
Usually Candida spp will infect the above tissues first before any blood tissue
i.e. blood is the last tissue to get infected
Imaging studies are most sensitive when neutropenia has resolved as abscesses will then form (especially for hepatosplenic candidiasis).
* so you WAIT till neutrophils is back UP before chest CT**
Fever in cancer patients : A quick note about invasive aspergillosis
Patients with severe (ANC <100 cells/mL) AND prolonged neutropenia (> 10 days)
- Usually bone marrow transplant patients
- Patients with AML (“strong” chemotherapy)
Invasive pulmonary aspergillosis
- Blood vessel and alveolar invasive disease
- High mortality rate
Treatment is usually with Voriconazole IV (best results of all antifungals for this) until radiographic resolution (may take 1 – 2 months, AT LEAST).
Fever in Cancer patients; Thoughts on Empiric Antiviral treatment?
There is NO ROLE for empiric antiviral treatment unless there is an obvious clinical need:
- Characteristic rash
i. e. varicella/shingles or herpes - Severe respiratory illness
i. e. influenza, COVID (VERY IMPORTANT)
What is the Duration of Therapy for Cancer Fever Neutropenic patients on Antimicrobials/virals
Antimicrobials/virals are continued: For the duration of a specific illness treatment - At least 10 – 14 days AND - Until no fever AND - At least until ANC >500 cells/mL
If NO bacteremia and/or source identified
- Until no fever AND
- At least until ANC >500 cells/mL
What is the Duration of Therapy for Cancer Fever Neutropenic patients on Antifungals
If antifungals are started:
Documented fungal invasive disease
- Need to rule out liver and eye disease (Candidiasis)
- Treat at least until radiographic improvement (eg. Aspergillosis)
- Usually at least 1 month
No documented disease
- Treat until you can rule out hepatosplenic candidiasis and candidal retinitis
How to treat fever in BONE MARROW transplant patients?
read the three slides
Take home points for Febrile neutropenia in cancer patients
- when is empiric use of vancomycin needed
High morbidity and mortality
Swift and empiric therapy is required
Must cover: Gut organisms (including anaerobes) Pseudomonas aeruginosa Staphylococcus aureus Respiratory organisms
Empiric use of vancomycin is not needed unless:
Shock
Mucositis
Line sepsis
Known MRSA
Known bacteremia with gram positive cocci
Febrile neutropenia in cancer patients Take Home Points on Empiric Use of
a. Antifungals
b. Antivirals
Empiric use of antifungals is not needed unless:
- Clinical presentation of invasive fungal disease
- Antifungals are ADDED if fever persists after 4 days
Empiric use of antivirals is not needed unless:
Clinical presentation of a treatable viral illness
*Especially symptoms of INFLUENZA
Signs of Odontogenic Infections
Face DISTORTED
Hand on the swelling because it is painful
REDNESS
ESPECIALLY IF: The mouth is OPEN, if tongue is protruded = airway issue
think of painting
How does facial swelling and facial space involvement occur secondary to an odontogenic infection?
These lectures will consider infections arising from the pulp ( the nerve) , although the same manifestations can arise from infections of:
- Periodontal Origin ( gum infection)
- Peri-coronal Origin (semi impacted wisdom tooth)
- Traumatic Origin
- Post-dental /surgical Origin
Odontogenic Infections can spread via:
4 & #5 occur if infection is draining into the mouth
- DIRECT EXTENSION***** [most common way, rest you think of in immunocompromised patients]
- Lymphatic spread
- Hematologous spread
- Ingestion (rare-HCl acidity in stomach)
- Aspiration
The outcome of the odontogenic infection is dependant on:
- The virulence of the organisms
- The host’s resistance [ patient’s ability to fight plays a significant role]
- The anatomical pathways of the spread of infection via direct extension
Immunodepressed or compromised patients Include:
Malnourished, especially secondary to alcoholism
Cancer / radiation / chemotherapy
Poorly controlled diabetic
Steroids or other immunosuppressive drugs
3 routes of the spread of Infection, Dental Abscess
There are 3 routes of the spread of this infection by DIRECT EXTENSION
Infection perforates the cortical plates of the maxilla or mandible , and the periostium and:
- Drains into the oral cavity [ideal, safely drains]
- Drains onto the skin [on cheek, mandible]
- Tracts into deeper fascial planes and spaces
Infraorbital Space (Canine Space) clinical picture
Clinical picture:
swelling pointing toward eye
no trismus- not able to open your eye fully
From the maxillary canine tooth
Eye tooth
top right canine of patient (1, 3)
INFECTION here leads to inability to open right eye
Buccal Space
- Clinical picture
Bound medially by the buccinator muscle
Bound laterally by subcutaneous tissue and skin
Clinical picture:
cheek swelling (as if they are holding their breath)
no trismus
Sublingual Space
Submandibular Space
related to lower teeth esp wisdom teeth
2 spaces separated by the Mylohyoid line
infection draining above this mylohyoid muslce: gets into sublingual space
- swelling here will impair talking because TONGUE is infected by this
- tongue may even protude out of the mouth
Sublingual Space
- Clinical Picture*
Occupies the floor of the mouth between the mucosa and the mylohyoid muscle
Clinical Picture:
elevation of the tongue (difficult to speak)
elevation floor of mouth
- has their mouth involuntarily open because of tongue elevation
Communicates with the submandibular space posteriorly
Submandibular Space
- clinical picture
Lies below the mylohyoid muscle
Clinical picture:
Firm, ill –defined swelling below the anterior border of the mandible
Tender to palpation
Trismus: is difficulty opening the mouth
Ludwig’s Angina
Aggressive rapidly spreading cellulitis involving:
Bilateral Submandibular Spaces
Bilateral Sublingual Spaces
And the Submental Space
Emergent situation, loss of airway eminent
need to treat immediately to avoid DEATH
Parapharyngeal Spaces
Divided into 3 spaces:
Pterygomandibular Space Lateral pharyngeal Space Retropharyngeal Space
Fascial Spaces of the Head and Neck
- The fascial layers of the head and neck represent connective tissue sheaths that surround and enclose potential spaces
- These potential spaces offer little resistance to the spread of infection
- These spaces are all potentially interconnected to eventually reach the brain or the mediastinum
The clinical findings of an acute odontogenic infection are based on the cardinal signs of inflammation:
Pain Swelling Warmth over the affected area Loss of function: (e.g. trismus [can't open wide], dysphagia [difficulty swallowing], dysphonia [difficulty pronouncing words] ,dyspnea [difficulty breathing]) Redness
Acute Inflammatory Reaction
- Inoculation of bacteria
- Cellulitis in the pulp, then
- Abscess in the pulp, then
- Cellulitis, or abscess at the peri-apical area, then
- Cellulitis of the surrounding soft tissue spaces, then
- Abscess of the surrounding soft tissue spaces
This is the evolution of the infection, in order
without treatment
