Saima Abbas M.D Infectious Diseases Fellow-PGY5. FEBRILE NEUTROPENIA. Why is this an Oncologic emergency ??. Infection + ABX + Immune system = cure. Normal Gross Anatomy Skin Integrity Intact mucous membranes Intact ciliary function Absence of Foreign Bodies. Innate Immunity
Macrophages, NK cells, Mast cells and basophils)
T cells CD 4 and CD 8
You are paged at 5:00am by the nurse taking care of Mr. Thomas on 4 AB
He spiked a fever of 38 C (100.4F) one hour ago.
-There is no order for Tylenol.
Per sign out:
The patient was recently diagnosed with AML is S/P chemotherapy and is stable.
Am I missing febrile Neutropenia???
(100.4F) on two occasions separated by 1 hour
You request her to repeat the temperature and she reports 38. 2 C (100.8 F)
decline to 500/mm
~ Clin Inf Dis, 2002;34:730-51
(Total # of WBC) x (% of Neutrophils) = ANC
Retrospective data have shown that
~Journal of Infectious diseases, 1978;147:14
Viscoli et al, Clin Inf Dis;40:S240-5
IATG-EORTC 1973-2000 trials of febrile neutropenia
Gram negative resurgence
~ response rates to initial antimicrobial therapy was 95%, compared to only 32% in patients with more than 14 days of neutropenia ( <.001)
~ patients with intermediate durations of neutropenia between 7 and
14 days had response rates of 79%
Gram-positive cocci and bacilli
Ensure Hemodynamic Stability and No NEW ORGAN DYSFUNCTION
-White cells, haemoglobin, platelets
-Electrolytes, urea, creatinine, Liver function
-Blood cultures (peripheral and all central line lumens)
-Oral ulcers or sores –send swabs ( Viral Cx and fungal Cx )
-Exit site swabs
-Urine Cultures (SSx/Foley Catheter) [- pyuria ?? UA]
-Stool Cultures and CDiff Toxin/PCR
-Chest Xray +/- CT abdomen/pelvis
infection is suspected and thrombocytopenia is absent or manageable.
3.Underlying malignancy and status
4.Co-morbidities, age >60
a Concomitant condition of significance (e.g.,shock, hypoxia, pneumonia,
or other deep organ infection, vomiting, or diarrhea).
~ Oral ciprofloxacin plus amoxicillin/clavulanate
~ Oral ciprofloxacin plus clindamycin
for PCN allergy
Mono or dual therapy + VANCOMYCIN
1. an aminoglycoside
an antipseudomonal penicillin
(with or without a beta-lactamase inhibitor)
(2) ciprofloxacin plus an
1. clinically suspected serious catheter-related infections
2. known colonization with penicillin- and
cephalosporin-resistant pneumococci or MRSA,
3. positive results of blood culture for gram-positive
5. H/O ciprofloxacin or trimethoprim-sulfamethoxazole
If not allergic to cephalosporins
~Aztreonam +/- Aminoglycoside or a FQ
+/- Vancomycin if indicated
MAINTAIN BROAD SPECTRUM ACTIVITY FOR A MINIMUM OF 7 DAYS OR UNTIL ANC >500
Moulds and Resistant Candida
( C. Krusei and C. glabrata )
Low risk patients
FOR BOARDS use AmphoB OR Itraconazole- hopefully should not ask you to choose between Itraconazole and Ampho B
** CID 40:1087&1094,2005
Granulocyte TransfusionsGranulocyte transfusions are not recommended for routine use.
~ Carbapenems were associated with increased Pseudomembranous colitis.
Hickman placed and Chemotherapy initiated
Experiences chills with CVC flushing and erythema and tenderness is noted over the hickman exit site.
A Stop Cefepime
B Add G- CSF
C Continue Cepepime until ANC > 500 or a minimum of 7 days.
D Continue Vancomycin for a total of 7 days.