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    Microsoft Word - Neutropenic Fever

    Uploaded by

    João Paulo Gregorio
    Neutropenia Febril

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Microsoft Word - Neutropenic Fever

    Uploaded by

    João Paulo Gregorio
    32 views1 page
    Neutropenia Febril

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Neutropenia Febril

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views1 page

    Microsoft Word - Neutropenic Fever

    Uploaded by

    João Paulo Gregorio
    Neutropenia Febril

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Neutropenic

    fever
    Neutropenia: Defined technically as PMN (ANC) < 500, but usually people get worried by <1000
    Fever: Temp >38.3, or >38.0 for >1h

    Pathophys:
    - Increased destruction/consumption/sequestration
    o Severe infection is most common cause (eg pneumococcal pneumonia)
    - Decreased production
    o Aplastic is most common cause (eg 2/2 chemo, less commonly 2/2 nutritional deficiency)
    o Bone marrow infiltration (granulomatous, inflamm, infection, malig)
    o Fibrosis (eg myeloproliferative disorders)

    Pathogens:
    - gram positives > GNR >> anaerobes, viruses
    - Fungal infection more likely if prolonged neutropenic fever (>7d) or severe neutropenia (<100)
    - MCC = line infection, pulmonary, soft tissue/perianal

    Greatest determinants of infection risk: ANC and e/o mucosal destruction (translocation of bacteria)


    If pt has neutropenic fever: 40% chance there is an infection!
    Thus, always start antibiotics, ideally within 30 min!! Mortality benefit.

    W/u:
    - look for localizing signs (though body often cant mount physical exam or CXR signs, so diagnostics are limited)
    o Exam:
    ! Oral, including teeth | lines | skin | perirectal (but no rectal exam!)
    ! Repeat exam frequently!
    o UA/UCx (culture even if UA neg)
    o Blood cultures are critical!
    o CXR (consider CT scan if suspicious b/c 40% of the time, CXR are nl)

    Treatment:
    - sick or not sick? (look at hemodynamics)
    o if this is a clinic pt and s/he doesnt look sick, can consider outpatient tx with fluoroquinolone
    - Abx (Tam et al, Internal Medicine Journal, 41 (2011) 90-101)
    o Cefepime or zosyn or penem (or aztreonam if allergic)
    ! (penem " increased risk of C diff, seizures)
    o +/- vanc (at Moffitt, always give vanc b/c high MRSA rates; but studies dont support)
    ! Cochrane 2005: adding vanc doesnt change outcomes, but include if suspect catheter
    infection, resistant Strep pneumonia, MRSA, hypotension or CV impairment
    o If SIRS, also add aminoglycoside (eg gentamicin, tobramycin; but increased risk of renal and hearing
    impairment)
    - Duration:
    o If known source: treat for typical duration for source + 48h after last fever/not neutropenic
    o If unknown source: minimum 7d + 48h after febrile/not neutropenic
    - No role for GCSF (Clark et al, J of Clinical Oncology, June 2005)
    o doesnt improve mortality but can shorten hospitalization
    o consider if bacterial infections arent controlled, or severe uncontrollable funcgal infections

    Time course
    - mean time to defervesce is 3-5d
    o so, dont change abx just b/c pt is still febrile! Though if pt looking sicker, may broaden coverage (eg
    add vanc)
    - if profoundly neutropenic (ANC<100) or prolonged neutropenic fever (>7d), add fungal coverage (fluc, vori)
    cover aspergiullus, candida

    UCSF CRI guidelines
    - neutropenia: moxifloxacin + fluconazole or voriconazole for prophylaxis
    - Neutropenic fever: vanc + cefepime
    - If worsening infection, change to vanc + imipenem + tobra
    o For fungal: change from fluconazole to vori. If already on vori, add aspofungin
    - If no response or continue to worsen: add septra for stenotrphomonas, change caspo to ampho

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