Febrile Neutropenia Done by Asma Essa AlTameem

Definition

Febrile neutropenia occurs when a patient has a fever and a

significant reduction in a type of white blood cells, known as

neutrophils, which are needed to fight infections.

Neutropenia is defined as an absolute neutrophil count (ANC) of less than

500/µL, or less than 1000/µL with an anticipated decline to less than 500/µL in

the next 48-hour period.

Neutropenic Fever is a single oral temperature of 38.3º C (101º F) or a

temperature of greater than 38.0º C ( 100.4º F) sustained for more than 1 hour in

a patient with neutropenia

Predisposing Factors

1. Malignancy : Type , Stage , Advanced or Refractory , Obstructive

2. Leukemia and lymphomas, which are malignancies of the hematopoietic system, are associated with a particularly high

incidence of neutropenia

3. Surgical Risk

4. Chemotherapy

5. Irradiation

6. Grade of Neutropenia

7. Mucosal breakdown : Mucositis

8. Patients with cancer typically have other potential entry points for infection, including IV catheters, sites of surgical

manipulation , and areas of abnormal anatomic architecture created by the tumors themselves

9. Medications : Corticosteroid Use

Microbiology Mainly Gram-Positive organisms (~70%)

Coagulase-negative staphylococci

Staphylococcus aureus

Streptococcal viridans

Enterococci

Gram-Negative organisms

Coliforms (E.coli, Klebsiella, Enterobacter)

Pseudomonas aeruginosa

Yeast

Candida

Aspergillus

Viruses

Herpes simplex (HSV)

Influenza, paranifluenza

CMV

Microbiology

Neutropenic patients are vulnerable to numerous infectious organisms

Gut (eg, Escherichia coli, Enterobacter, anaerobes)

Skin (eg, Staphylococcus, Streptococcus)

Respiratory Tract (eg, Streptococcus pneumoniae, Klebsiella, Corynebacterium, Pseudomonas)

Other areas that are susceptible to opportunistic colonization (eg, by Clostridium difficile,

Mycobacterium, Candida, Aspergillus).

Diagnosis

History

Physical Examination

Lab Assessments

Diagnostic Imaging

Medical History

Chemotherapy regimen & last dose given

Prophylactic antibiotic

Steroid use

Major comorbidities

Recent surgical procedures

Recent infections or positive cultures

Previous antibiotic-resistant organisms or bacteraemia

Recent exposures

Presence of vascular devices

Allergies

Physical Examination Site Signs

Skin No skin lesions associated with central venous access device

Oro-pharyngeal tract No mucositis

Gastrointestinal tract No nausea , vomiting , or dysphagia

Respiratory tract Presence Mild cough

Genitourinary tract Presence of yeast infection

Central nervous system No CNV symptoms

Lab Assessments

CBC

RFT : electrolytes , Cr , BUN

LFT

Coagulation screen

C- reactive protein

Urinalysis

Stool microscopy for C.difficle if patient has diarrhea

Lab Assessments

Blood cultures

1 catheter + 1 peripheral

2 catheter

2 peripheral

Urine culture

if symptomatic

urinary catheter

or abnormal urinalysis

Stool culture , if patient has diarrhea

Skin lesion swab , biopsy and culture

Sputum culture , if patient has productive cough

Diagnostic Imaging

Chest X rays

Brain CT , MRI ; if patient has CNS symptoms

Abdominal Ct , US ; if patient has abdominal pain

Risk Assessment

The Multinational Association for Supportive

Care in Cancer (MASCC) Risk Index

Low – Risk Patient

Less than 7 days ( duration of neutropenia )

ACN more than 100/µl

Outpatient status at the time of fever

Normal findings on chest x rays

No associated acute comorbidities

No hepatic or renal insufficiency

MASCC Risk Index score >21

Early evidence of bone marrow recovery

High– Risk Patient

More than 7 days ( duration of neutropenia )

Profound neutropenia , ACN less than 100/µl

Inpatient status at the time of fever

CrCl less than 30

MASCC Risk Index score <21

Significant medical comorbidities :

Hypotension

Pneumonia

New-onset abdominal pain

Neurologic changes

Treatment

IV Monotherapy

B-lactams

Cefepime

Imepinum

Meropenum

Tazobactum

IV Combination Therapy

Aminoglycoside + (meropenem, imipenem-cilastin or piperacillin-tazobactam)

Aminoglycoside + (cefepime or ceftazidime)

Ciprofloxacin + (meropenem, imipenem-cilastin or piperacillin-tazobactam)

Piperacillin-tazobactam

Broad spectrum gram(-), gram(+) & anaerobic coverage

Imipenem-cilastin – Meropenem

Broad spectrum gram(-), gram(+) & anaerobic and ESBL coverage

Meropenem is Preferred for meningitis/CNS infection

Ceftazidime

Poor gram(+) activity

Good CSF penetration

Aminoglycosides

Gram(-) coverage, synergy with beta-lactams against S.aureus and Enterococcus

Side effects :Nephrotoxicity, ototoxicity

Ciprofloxacin

Gram(-) and atypical bacterial coverage

less gram(+) activity than other options

Avoid in patients recently treated with quinolone prophylaxis

Vancomycin

Vancomycin not routinely recommended for empiric therapy

Specific indications:

Clinically suspected serious catheter-related infection

Known colonization with MRSA or pcn/ceph-resistant pneumococci

Gram-positive bacteremia pending further C&S

Hypotension or other cardiovascular impairment

Soft-tissue infection

Risk factors for viridans strep bacteremia (severe mucositis )

Reassess Vancomycin after 24-48 hours

Fungal Infection

Antifungal Considered if the patient is febrile after 3-5 days and remains

neutropenic

Liposomal Amphotericin B = aspergillosis, candida

Fluconazole = Candida species

Voriconazole = fluconazole-resistant Candida, amphotericin-B-resistant

Aspergillus

Caspofungin = Candida, Aspergillus , and Histoplasma

It is active against fluconazole-resistant and fluconazole-susceptible strains of Candida

albicans.

Antiviral Acyclovir , Valacyclovir:

HSV or VZV treatment

Ganciclovir:

CMV treatment

Foscarnet:

Acyclovir-resistant HSV , CMV treatment

Oseltamivir:

Influenza - reduced doses required in renal impairment

When to add antiviral drugs?

Oral lesions: HSV

Esophageal lesions: HSV, CMV

Skin lesions: VZV

Pneumonia: Influenza

CNS symptoms: HSV

Nursing Management

Nursing Management

Monitor pt’s VS every 2 hrs and look for clinical symptoms ( lesion , cough )

Administer medication as ordere

Maintain aseptic technique

Provide antibacterial diet

Daily F/U with lab results (CBC , NE ,RFT)

Educate the pt