Neutropenic fever: Difference between revisions
 
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==Background==
==Background==
*ANC = (total WBC) x (%segs + %bands)
{{Neutropenia background}}
*Nadir usually occurs 5-10d after chemo
*Duration of neutropenia depends on type of cancer treatment
**Solid tumor Rx: <5d
**Hematologic malignancies: 14d or longer
*(Leukemia or lymphoma) + chemo most commonly associated with neutropenia


===Definition===
===Common Causes===
#ANC <500 OR <1000 w/ predicted nadir of <500 in 48h AND
''Definitive cause only found in 30%''
#Fever ≥ 38.3˚C (100.9˚F) once OR sustained temp ≥38 (100.4) for >1hr
*Endogenous flora 80%
##Oral temp (do not obtain rectal temp)
**[[E. Coli]], [[Enterobacter]], [[anaerobes]]
*Skin
**[[Staph]], [[strep]]
*Respiratory tract
**[[Step pneumonia]], [[klebsiella]], [[corynebacterium]], [[pseudomonas]]
*Other
**[[C. diff]], [[mycobacterium]], [[candida]], [[Aspergillosis|Aspergillus]]
 
===High-Risk/Special Infections===
*[[Neutropenic enterocolitis (typhlitis)]]
*[[Mucormycosis]]
*Hepatosplenic [[Candidiasis]]
**Occurs after neutropenic fever resolves and ANC has come up allowing abscess formation
**Treat with [[amphotericin B]]


===Common Causes===
==Clinical Features==
*Definitive cause only found in 30%
*[[Fever]]
#Endogenous flora 80%
*Classic manifestations of infection are frequently NOT seen
##E Coli, Enterobacter, anaerobes
*Check skin, oral cavity, perianal area, entry sites of indwelling cath sites
#Skin
##Staph, strep
#Respiratory tract
##Step pneumo, klebsiella, corynebacterium, pseudomonas
#Other
##C. diff, mycobacterium, candida, aspergillus


==Diagnosis==
==Differential Diagnosis==
#Classic manifestations of infection are frequently NOT seen
*[[Transfusion reaction]]
#Check skin, oral cavity, perianal area, entry sites of indwelling cath sites
*Medication allergies and toxicities
*Tumor-related fever


==DDx==
{{Oncologic emergencies DDX}}
#Transfusion reaction
#Medication allergies and toxicities
#Tumor-related fever


==Work-Up==
==Evaluation==
#AVOID rectal temp
''Patient should be placed and maintained on neutropenic isolation precautions during there stay in the ED and while in the hospital''
#CBC
===Workup===
#Chemistry
'''AVOID rectal temp or digital rectal exam'''
#LFTs
*CBC
#UA/UCx
*Chemistry
##May not show WBCs or leuk esterase given neutropenia
*[[LFTs]]
#Sputum studies
*[[Urinalysis]]/Urine culture
##Gram stain
**May not show WBCs or leuk esterase given neutropenia
##Cx
*Sputum studies
#BCx x 2
**[[Gram stain]]
##20-30cc blood (adult); 3-9cc (child)
**Culture
##May take both samples from CVC (if present)
*[[Blood culture]] x 2
#Cx any indwelling catheters
**Take at least one sample from central line, if present
#LP
*Culture any indwelling catheters
##If neuro abnl or suspicious
*[[LP]]
#Site-specific specimens
**If neuro findings or suspicious
##Nasopharyngeal wash (in pts with URI)
*Site-specific specimens
###RSV, influenza
**Nasopharyngeal wash (in patients with URI)
#Stool (if indicated)
***[[RSV]], [[influenza]]
##C dif
*Stool (if indicated)
##O&P
**[[C dif]]
##Cx
**O&P
#CXR
**Cultures
#CT (if necessary)
*[[CXR]]
##Sinuses
*CT (not required in all patients)
##Chest
**Sinuses
##A/P
**Chest
**Abdomen/Pelvis
***Should have high suspicion, given risk of [[typhlitis]]


===High-Risk/Special Infections===
===Diagnosis===
#[[Neutropenic Enterocolitis (Typhlitis)]]
{{Neutropenic fever definition}}
#[[Mucormycosis]])
#Hepatosplenic Candidiasis
##After neutropenic fever resolves and ANC has come up allowing abcess formation
##Treat w/ amphotericin B


==Treatment==
==Management==
#If suspect infection then treat (even if afebrile)
{{Neutropenic fever treatment}}
##3rd or 4th gen cephalosporin (cefepime 2g or ceftazidime 2g) OR
##Carbapenem (imipenem 500mg or meropenem 1g) OR
##Zosyn 4.5g +/- aminoglycoside (gent 2-5mg/kg, amikacin) OR
##Antipseudomonal fluoroquinolone (moxi, levo, cipro) +/- vanco
#Add Amphotericin B 0.5-1 mg/kg qd if fever >72 h or candida in esophagus, urine or stool
#Add anaerobic coverage (clindamycin, metronidazole) if peritonitis or abd pain


==Disposition==
==Disposition==
*Low risk patients
*Low risk patients  
**Consider discharge it pt scores ≥21 using the MASCC risk index scoring system
**Brief (<7d duration) of neutropenia with few comorbidities<ref>Freifeld AG et al. Clinical practice guideline for the use of antimicrobial agents in
neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93.</ref>
**Consider discharge it patient scores ≥21 using the MASCC risk index scoring system
**Score ≥21 associated with <5% risk for severe complications and mortality <1%


===Patient Clinical Factor Score===
===MASCC Risk Index===
*The MASCC study was an international collaboration to derive and validate a scoring system to identify low-risk patients for complications of febrile neutropenia.<ref>Klatersky et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Onc 18:3038-3051.</ref>
{| class="wikitable"
| '''Characteristic '''
| '''Points'''
|-
|
No or Mild Symptoms


{| width="340" border="1"
Moderate Symptoms
| Patient Clinical Factor
 
|Score
Severe Symptoms
|-
 
|
|  
Severity of illness:
5


no symptoms or mild symptoms
3


moderate symptoms
0
|
5


3
|-
|-
| No hypotension<br />
| No [[Hypotension]](SBP<90)
| 5<br />
| 5
|-
|-
| No chronic obstructive pulmonary disease<br />
| No COPD
| 4<br />
| 4
|-
|-
| Solid tumor or no fungal infxn<br />
| Solid tumor '''OR''' no previous fungal infection
| 4<br />
| 4
|-
|-
| No dehydration<br />
| No dehydration requiring IV fluids
| 3<br />
| 3
|-
|-
| Outpt at onset of fever<br />
| Outpatient status at fever onset  
| 3<br />
| 3
|-
|-
| Age < 60yo<br />
| Age <60yr
| 2<br />
| 2
|}
|}


≥21 pt = low risk for SBI
===CISNE===
*Clinical Index of Stable febrile Neutropenia
*230 febrile neutropenia, chemo-therapy induced, retrospective analysis of MASCC vs. CISNE<ref>Coyne et al. Application of the MASCC and CISNE Risk-stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department. Ann Emerg Med. 2016 Dec 29. pii: S0196-0644(16)31352-X. doi: 10.1016/j.annemergmed.2016.11.007.</ref>
**MASCC was ~55% specific and CISNE was ~98% specific with PPV ~98%
 
==See Also==
*[[Neutropenia]]
 
==External Links==
*https://www.mdcalc.com/calc/3913/mascc-risk-index-febrile-neutropenia
*https://www.mdcalc.com/calc/3997/clinical-index-stable-febrile-neutropenia-cisne


==Source==
==References==
*LLSA 2009
<references/>
*Halfdanarson, Onc Emergencies Mayo Clin Proc June 2006
*Tintinalli


[[Category:Heme/Onc]]
[[Category:Heme/Onc]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 21:36, 11 September 2024

Background

Neutropenia

  • ANC = (total WBC) x (%segs + %bands)
  • Nadir usually occurs 5-10 days after chemotherapy
  • Duration of neutropenia depends on type of cancer treatment
    • Solid tumor treatments: <5 days
    • Hematologic malignancies: 14 days or longer

Common Causes

Definitive cause only found in 30%

High-Risk/Special Infections

Clinical Features

  • Fever
  • Classic manifestations of infection are frequently NOT seen
  • Check skin, oral cavity, perianal area, entry sites of indwelling cath sites

Differential Diagnosis

Oncologic Emergencies

Related to Local Tumor Effects

Related to Biochemical Derangement

Related to Hematologic Derangement

Related to Therapy

Evaluation

Patient should be placed and maintained on neutropenic isolation precautions during there stay in the ED and while in the hospital

Workup

AVOID rectal temp or digital rectal exam

  • CBC
  • Chemistry
  • LFTs
  • Urinalysis/Urine culture
    • May not show WBCs or leuk esterase given neutropenia
  • Sputum studies
  • Blood culture x 2
    • Take at least one sample from central line, if present
  • Culture any indwelling catheters
  • LP
    • If neuro findings or suspicious
  • Site-specific specimens
  • Stool (if indicated)
  • CXR
  • CT (not required in all patients)
    • Sinuses
    • Chest
    • Abdomen/Pelvis
      • Should have high suspicion, given risk of typhlitis

Diagnosis

Neutropenic fever definition

  • ANC <500 OR <1000 with predicted nadir of <500 in 48h AND
  • Fever ≥ 38.3˚C (100.9˚F) once OR sustained temperature ≥38 (100.4) for >1hr
    • Oral temperature (do not obtain rectal temp; risk of inducing bacteremia[1])

Management

Therapy is aimed at treating multiple flora that include Gram Negatives, Gram Positive Bacteria, Pseudomonas and if there is an indwelling catheter or high risk, then MRSA.

Inpatient

Outpatient

Disposition

  • Low risk patients
    • Brief (<7d duration) of neutropenia with few comorbidities[4]
    • Consider discharge it patient scores ≥21 using the MASCC risk index scoring system
    • Score ≥21 associated with <5% risk for severe complications and mortality <1%

MASCC Risk Index

  • The MASCC study was an international collaboration to derive and validate a scoring system to identify low-risk patients for complications of febrile neutropenia.[5]
Characteristic Points

No or Mild Symptoms

Moderate Symptoms

Severe Symptoms

5

3

0

No Hypotension(SBP<90) 5
No COPD 4
Solid tumor OR no previous fungal infection 4
No dehydration requiring IV fluids 3
Outpatient status at fever onset 3
Age <60yr 2

CISNE

  • Clinical Index of Stable febrile Neutropenia
  • 230 febrile neutropenia, chemo-therapy induced, retrospective analysis of MASCC vs. CISNE[6]
    • MASCC was ~55% specific and CISNE was ~98% specific with PPV ~98%

See Also

External Links

References

  1. ↑ Fleischman RJ. Emergency Complications of Malignancy. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed December 09, 2020. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158&sectionid=162273381
  2. ↑ 2.0 2.1 Friefeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93 fulltext
  3. ↑ Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clinical Infectious Disease 2002; 34:730-751
  4. ↑ Freifeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93.
  5. ↑ Klatersky et al. The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Onc 18:3038-3051.
  6. ↑ Coyne et al. Application of the MASCC and CISNE Risk-stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department. Ann Emerg Med. 2016 Dec 29. pii: S0196-0644(16)31352-X. doi: 10.1016/j.annemergmed.2016.11.007.
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