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Febrile Neutropenia. Mervat Hesham 2009. Febrile Neutropenia. Who should receive empirical Rx? When should empirical Rx be started? What is appropriate initial Rx? How should initial Rx be modified? How long should empirical Rx be continued?. Febrile neutropenia. *Fever

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Febrile neutropenia

Febrile Neutropenia

Mervat Hesham

2009


Febrile neutropenia1
Febrile Neutropenia

  • Who should receive empirical Rx?

  • When should empirical Rx be started?

  • What is appropriate initial Rx?

  • How should initial Rx be modified?

  • How long should empirical Rx be continued?


Febrile neutropenia2
Febrile neutropenia

*Fever

Single oral temperature > 38.3ºC

OR

  • 38º C for more than 1 hour

    *Neutropenia

  • Neutrophils< 0.5x109/L (500/mm3)

    OR

  • Neutrophils <1.0 x109/L, predicted fall to < 0.5 x 109/L

    • Tympanic temperature (oral temperatures may be falsely high in presence of mucositis)


Neutropenia anc mild 1 0 to 1 5 x 10 3 l moderate 0 5 to 1 0 x 10 3 l severe 0 5 x 10 3 l

Neutropenia:(ANC)

mild  1.0 to 1.5 x 103/l

moderate  0.5 to 1.0 x 103/l

Severe  <0.5 x 103/l


Possible sites of infection
Possible sites of infection

  • URTI

  • Dental sepsis

  • Mouth ulcers

  • Skin sores

  • Exit site of central venous catheters

  • Anal fissures

  • GIT

  • marrow aspiration sites

  • nails and nail peds, scalp


Factors associated with increased risk of infection
Factors Associated with Increased Risk of Infection

  • Duration and severity of neutropenia

  • type and intensity of chemotherapy

  • altered phagocytic, cellular and humoral immunity

  • breaches of skin and mucosal barrier

  • catheter or other foreign bodies

  • underlying diseases or therapy

  • corticosteroids


Pathogens
Pathogens

  • 60% - 70% of fevers during neutropenia have

    no identifiable etiology i.e fever of unknown

    origin.

  • Bacteremia seen in 10%- 20% of patients with

    fever and neutrpenia,

    Gram positive bacteremia 70%

    Gram negative bacteremia 30%


Common pathogen in neutropenia
Common pathogen in neutropenia

Bacteria:

Gram positive organisms

  • Staphylococcus aureus

  • Coagulase-negative staphylococcus

  • alpha and beta hemolytic streptococcus

    Gram negative organisms

  • Escherichia coli

  • Klebsiella pneumoniae

  • Pseudomonas aeruginosa

    Fungi:

  • Candida , Aspergillus


Febrile neutropenia evaluation
Febrile Neutropenia Evaluation:

  • A. General measures:

    Attempt to reduce acquisition of resistant hospital pathogens in neutropenic patients by using the following precautions:

  • 1. Single-bed room (“protective isolation”).

  • 2. Wash hands with antibacterial soap prior to all patient contact.

  • 3. No live plants.

  • 4. Limit visitors.

  • 5. Meticulous skin care, especially IV catheter sites.

  • 6. Foley catheters, rectal thermometers, and suppositories should be avoided.


  • B. Avoid routine use of antipyretics and corticosteroids so that temperature trends and response to antibiotics can be monitored. Acetaminophen may be used for discomfort associated with fever.

  • C. Examine the patient frequently

    History :

    (cycle/course of chemotherapy,prophylactic agents, corticosteroids , immunosuppresive agents,previous infections or procedures).


  • Physical examination :

    *Signs(perianal erythema and tenderness, Minimal erythema or serous discharge at the site of a Hickman catheter, Signs & Symptoms of Sepsis (any one or more of the following signs):

    1. Hyperpyrexia (Temperature > 104oF).

    2. Hypothermia (< 96oF).

    3. Chills not associated with transfusions or drugs

    4. Hypotension (BP change > 30% or SPB < 90 mmHg; refer to age specific guidelines for children).


5. Hypoxemia (O2 saturation < 90% or > 5% change from baseline).

6. Moderate/severe End Organ Dysfunction (increased Scr or LFTs).

7. Altered Mental Status.


D risk assessment
D baseline).. Risk assessment:

  • Low risk:

  • ANC > 100 /mm3 ,

  • Normal CXR ,

  • Duration of neutropenia< 7 d,

  • Resolution of neutropenia <10 d,

  • No appearance of illness,

  • No comorbidity complications ,

  • Malignancy in remission.

  • High risk :

  • ANC < 100 /mm3 ,

  • Duration of neutropenia > 7 d .


E investigation
ُُ baseline).E . Investigation

  • Full Blood Count

    -White cells, haemoglobin, platelets

  • Biochemistry

    -Electrolytes, urea, creatinine, Liver function

  • Microbiology

    -Blood cultures (peripheral and all central line lumens)

    -Exit site swabs

    -Wound swabs

    -Urine analysis and culture.

    -Stool analysis and culture.

    -+/- Cerebrospinal fluid

  • Radiology

    Baseline chest X-ray and any other X-ray indicated by exam. -+/- CT abdo/pelvis


  • F baseline).. Re-evaluate the patient daily (or more often if clinically indicated) for localizing signs of infection and for response to therapy. Unless the patient’s clinical status changes, allow at least 48 hours prior to modifying antibiotics.

  • G. Be alert for reappearance of fever in a patient who initially defervesces. This may indicate superinfection with resistant bacteria or with fungi.


Empirical antibacterial therapy
Empirical Antibacterial Therapy baseline).

Empiric antibiotic therapy Broad spectrum empiric antibiotic therapy must be started properly prior to organism identification.

Survival is greater than 90% when patients are treated with appropriate empiric therapy.


Initial empiric antibiotics rationale
Initial Empiric Antibiotics baseline).Rationale

  • Severe risk of bacterial sepsis

  • Insensitivity of diagnostic tests

  • Delays in identification of pathogens


Febrile neutropenia3
Febrile Neutropenia baseline).

  • Who should receive empirical Rx?

  • When should empirical Rx be started?

  • What is appropriate initial Rx?

  • How should initial Rx be modified?

  • How long should empirical Rx be continued?


Initial empiric antibiotics considerations
Initial Empiric Antibiotics baseline).Considerations

  • Broad spectrum of bactericidal activity

  • Local prevalence, susceptibility pattern

  • Antibiotic toxicity : well-tolerated, allergy

  • Host factors : severity of presentation

  • Prior antibiotic usage

  • Antibiotic costs

  • Ease of administration


Initial empiric antibiotics recommended choices
Initial Empiric Antibiotics baseline).Recommended choices

  • Monotherapy

  • Duotherapy without vancomycin

  • Vancomycin plus one or two drugs


Oral antibiotics and outpatient management
Oral Antibiotics and Outpatient Management baseline).

  • Current studies : potentially be safe and effective in low-risk patients


Monotherapy choices
Monotherapy baseline). Choices

  • Ceph 3 : ceftazidime

  • Ceph 4 : cefepime

  • Carbapenem : imipenem , meropenem

IDSA guidelines-2002


Combination therapy advantages
Combination Therapy baseline).Advantages

  • Increased bactericidal activity

  • Potential synergistic effects

  • Broader antibacterial spectrum

  • Limits emergence of resistance


Combination therapy disadvantages
Combination Therapy baseline).Disadvantages

  • Drug toxicities

  • Drug interactions

  • Potential cost increase

  • Administration time


Combination therapy choices
Combination Therapy baseline).Choices

  • Aminoglycoside + Anti-pseudomonal carboxypenicillin

  • Aminoglycoside + Anti-pseudomonal cephalosporin

  • Aminoglycoside + Carbapenem


Vancomycin as empiric rx when to use
Vancomycin as Empiric Rx baseline).When to use ?

  • Known colonization with MRSA or PRSP

  • Clinically suspected serious catheter-related infections (eg bacteremia)

  • Hypotension or cardiovascular impairment

  • Initial positive results of blood culture for G+ bacteria


Febrile neutropenia4
Febrile Neutropenia baseline).

  • Who should receive empirical Rx?

  • When should empirical Rx be started?

  • What is appropriate initial Rx?

  • How should initial Rx be modified?

  • How long should empirical Rx be continued?


Initial antibiotic modifications considerations
Initial Antibiotic Modifications baseline).Considerations

  • Persistence of fever

  • Clinical deterioration

  • Culture results

  • Drug intolerance/side effects


Persistent fever causes
Persistent Fever baseline).Causes

  • Nonbacterial infection

  • Resistant bacteria

  • Slow response to antibiotics

  • Fungal sepsis

  • Inadequate serum & tissue levels

  • Drug fever


Persistent fever 5 days choices of mx
Persistent Fever baseline).> 5 DaysChoices of Mx

  • Continue initial Rx

  • Change or add antibiotics

  • Add an antifungal drug(Ampho B)


Febrile neutropenia5
Febrile Neutropenia baseline).

  • Who should receive empirical Rx?

  • When should empirical Rx be started?

  • What is appropriate initial Rx?

  • How should initial Rx be modified?

  • How long should empirical Rx be continued?


Duration of antibiotic therapy when to stop
Duration of Antibiotic Therapy baseline).When to stop?

  • No infection identified after 3 days of Rx

  • ANC > 500 for 2 consecutive days

  • Afebrile > 48 hr

  • Clinically well


Empiric anti fungal therapy
Empiric baseline).anti-fungal therapy

  • Give Antifungal therapy if

    • Prolonged neutropenic fever (>4 days) and on Broad spectrum antibiotics

      * Esophagitis , localized pulmonary infiltrate.

      * Failure of treatment of diffuse pulmonary infiltrate by I.V TMP and erythromycin .

      * Sinus tenderness or nasal ulcerative lesion.

  • Rationale

    • Fungal infections difficult to diagnose

    • High mortality, excess morbidity with delays in treatment

  • Advantages

    • Fewer fungal deaths

  • Disadvantages

    • >50% of patients will be treated unnecessarily

    • Toxicity of antifungals and costs +++


Empirical antianaerobe therapy
Empirical antianaerobe therapy baseline).

  • In perianal tenderness .

  • severe oral mucositis and gingivitis, acute abdominal pain ( typhilitis , appendicitis. (


Supportive measures in febrile neutropenia

Supportive measures in febrile neutropenia baseline).

Colony Stimulating factors

(G-CSF, GM-CSF)


Colony stimulating factors in febrile neutropenia
Colony Stimulating factors in febrile neutropenia baseline).

  • Theoretical benefits

    • Reduce duration neutropenia

    • Reduce severity neutropenia

    • Reduce hospital stay

    • Reduce duration antibiotic therapy

    • Reduce alterations in chemotherapy regimens (dosage and timing)

    • Reduce infection-related mortality

    • Improve the effective delivery chemotherapy


Guidelines for use of csf in febrile neutropenia
Guidelines for use of CSF in febrile neutropenia baseline).

  • Primary prophylaxis

    • In chemo regimens with >40% risk of FN, most cost effective

    • Consider in pre-existing neutropenia, poor performance status, advanced malignancy

  • Secondary prophylaxis

    • If previous profound neutropenia, subsequent dose reduction preferred rather than giving CSF support with maximum intensity chemotherapy


Guidelines for use of csf in other clinical settings
Guidelines for use of CSF in other clinical settings baseline).

  • AML induction

    • Reduced duration neutropenia

    • No associated decrease in nadir, no reduction hospital stay, antibiotic usage or mortality risk

    • Trials esp in elderly variable

  • Combined chemotherapy and radiotherapy (mediastinal)

    • Relative Contraindication: increased risk thrombocytopenia

  • Febrile neutropenia with complicated sepsis

    • Adjuvant CSF given, benefit not confirmed


Hematopoietic growth factors
Hematopoietic growth factors : baseline).

(a) Patients already on growth factors should continue on therapy if febrile neutropenia develops. There is no rationale to increase the dose.

(b) Patients not on a growth factor should not be started unless certain prognostic factors predictive of clinical deterioration are present, including signs/symptoms of sepsis, pneumonia, or fungal infection.

(c) Do NOT give growth factors if the patient is receiving concurrent radiation therapy – a more prolonged neutropenia may result.


Febrile neutropenia conclusions
Febrile Neutropenia baseline).Conclusions

  • Significant morbidity & mortality

  • Choice of initial empiric therapy dependent on epidemiologic & clinical factors

  • Monotherapy as efficacious as combination Rx

  • Modifications upon reassessment

  • Duration dependent on ANC


  • Antipseudomonal penicillin baseline).

    * I/V Piperacillin 200-300mg/kg/daily

    ( IV Divided q4–6h)

    *I/V Ticarcillin 300mg/kg/daily

    ( IV Divided q4–6h)

  • Aminoglycosides

    *I/V Gentamicin 6.0–7.5 mg/kg/daily.

    (Loaded with 2mg/kg IV Divided q8h)

    *I/V Amikacin 7.5mg/kg/12 hourly

    ( 15 mg/kg/day IV Divided q8h)


Monotherapy
Monotherapy: baseline).

  • Monotherapy with certain broad spectrum antibiotic

    shown to be as effective as combination antibiotic

    regimen for empiric therapy.

  • Include,

    • Ceftazidime (3rd generation cephalosporin)( Fortum )

    100–150 mg/kg/day IV Divided q8h

    • Imipenam-cilastatin ( carbepenam )

    I/V 12.5mg/kg/6 hourly

    Meropenem 0–120 mg/kg/day IV Divided q8h

    ( maximum dose 6 g/day)

    • Cefepime (4th generation cephalosporin) ( Maxipim)

    50 mg/kg per dose IV Divided q8h

    or I/V 1-2gm/ 8 hourly


Oral antibiotic therapy
Oral antibiotic therapy: baseline).

  • Are acceptable for selective stable low risk patients.

    • Oral ciprofloxacin 750mg/8 hourly plus

    Amoxicillin/clavulanate500mg/8 hourly.


Antifungal therapy
Antifungal therapy baseline).

  • Amphotericin B (Fungizone)

    IV Test dose 0.1 mg/kg to a

    maximum dose of 1 mg over 1 hour; if tolerated, may use 0.4 mg/kg and increase to 1 mg/kg/day

  • Voriconazole( fevend )

    IV, PO 6 mg/kg every 12 hours, IV for first 24 hours and then 4 mg/kg every 12 hours.

    Oral dose:

    >40kg, 200 mg bid, may increase to 300 mg bid,

    <40 kg 100 mg bid, may increase to 150 mg bid

  • Fluconazole ( diflucan )

    IV, PO 2 mg/kg/day (maximum dose 600 mg/day)

    ( I/V or oral fluconazole 200mg loading dose then 100mg/daily for 10-14 days for candidiasis)


Antiviral therapy
Antiviral therapy baseline).

  • Acyclovir- (Zovirax) :Varicella in immuno compromised host

    *IV For children <1 year of age:

    30 mg/kg/day in 3 divided doses for 7–10 days; some

    * IV For children >1 year of age: 1500 mg/m2 of body surface area per day in 3 divided doses for 7–10 days.


  • Ganciclovir baseline).(Cytovene)

    1- Acquired CMV retinitis in immunocompromised Host

    *IV 10 mg/kg/day in 2 divided

    doses for 14–21 days;

    *For long-term suppression, 5 mg/kg/day

    for 5–7 days/week.

    2- Prophylaxis of CMV inhigh-risk host:

    IV 10 mg/kg/day in 2 divideddoses for 1 wk, then 5 mg/kg/day in 1 dose for 100 days.


Anaerobic coverage: baseline).

  • Metronidazole

    30 mg/kg/day IV (divided q6h)

    (loading dose initially 15 mg/kg)

  • Vancomycin

    40 mg/kg/day(maximum 2 g/day)

    IV Divided q6–8h

  • Clindamycin

    40 mg/kg/day IV Divided q6–8h


Thank you baseline).


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