Febrile Neutropenia Pathway

Febrile Neutropenia Pathway Diagnosis of Febrile Neutropenia: Neutropenia: ANC < 500 cells/m3 or expected decrease to <500 cells/m3 during the next 48 hours AND Fever: temperature >38 Labs: CBC with diff, CMP, Blood cultures Obtain 2 blood cultures at time of fever and with each subsequent fever. Perform complete Include 1 anaerobic culture bottle if concerned for anaerobic process physical exam but do Use central line for blood cultures when possible NOT perform rectal Other studies as clinically indicated: e.g. CXR, respiratory pathogen panel, exam stool studies, UA (no catheter specimens) Additional antibiotics: Empiric antibiotics: ADMINISTER ANTIBIOTICS When clinically indicated, First line: Cefepime WITHIN 1 HOUR OF consider addition of an If concerned for intra-abdominal process: Piperacillin-tazobactam PRESENTATION: agent to cover resistant gram- If concerned for cefepime-resistant organism: Meropenem DO NOT DELAY ANTIBIOTICS positive bacteria (e.g. Severe beta-lactam allergy: consult Infectious Diseases WHILE WAITING FOR LAB MRSA, coagulase-negative Concern for central nervous system infection: consult Infectious RESULTS staphylococcus, enterococcus). Diseases Options may include: Daptomycin, Ceftaroline, and IV fluid bolus(es) if indicated Vancomycin Re-evaluation at 48 hours of empiric therapy Positive culture obtained or source identified? NO YES If previously started, consider discontinuation of extended grampositivecoverage (e.g. daptomycin / vancomycin / Consult Infectious cefaroline),even if patient remains febrile Diseases to Continue other agent(s) and close clinical assessment determine appropriate Consider ID consult definitive treatment course Patient afebrile before 5 days YES NO YES Source identified? Patient remains febrile for 5 days or more*: NO Initiate empiric antifungal treatment Call Infectious diseases to decide best choice, appropriate infection workup and if formal consult needed Continue empiric antibiotics until ANC >200 and rising AND patient *Also applies if fever resolves and then recurs while on afebrile AND well-appearing antibiotics for 5 continuous days.

Copy Link

Recommended publications

Neutropenia Fact Sheet
Neutropenia in Barth Syndrome i ii (Chronic, Cyclic or Intermittent) What problems can Neutropenia cause? Neutrophils are the main white blood cell for fighting or preventing bacterial or fungal infections. They may be referred to as polymorphonuclear cells (polys or PMNs), white cells with segmented nuclei (segs), or neutrophils in the complete blood cell count (CBC) report. Immature neutrophils are referred to as bands. When someone is neutropenic (an abnormally low level of neutrophils in the blood), the risk of infection increases. The absolute neutrophil count (ANC) is a measure of the total number of neutrophils present in the blood. When the ANC is less than 1,000, the risk of infection increases. Most infections occur in the ears, skin or throat and to a lesser extent, the chest. These infections can be very serious and may require antibiotics to clear infections. When someone with Barth syndrome is neutropenic his defenses are weakened, he is likely to become seriously ill more quickly than someone with a normal neutrophil count. Tips: • No rectal temperatures as any break in the skin can lead to an infection. • If the individual has a temperature > 100.4° F (38° C) or has infectious symptoms, the primary physician or hematologist should be notified. The individual may need to be seen. • If the individual has a temperature of 100.4° F (38° C) – 100.5° F (38.05° C)> 8 hours or a temperature > 101.5° F (38.61° C), an immediate examination by the physician is warranted. Some or all of the following studies may be ordered: CBC with differential and ANC Urinalysis Blood, urine, and other appropriate cultures C-Reactive Protein Echocardiogram if warranted • The physician may suggest antibiotics (and G-CSF if the ANC is low) for common infections such as otitis media, stomatitis.
[Show full text]
Bloodstream Infections in Febrile Neutropenic Patients at a Tertiary Care Center in Lebanon: a View of the Past Decade
International Journal of Infectious Diseases (2007) 11, 450—453 http://intl.elsevierhealth.com/journals/ijid Bloodstream infections in febrile neutropenic patients at a tertiary care center in Lebanon: a view of the past decade Zeina A. Kanafani a, Ghenwa K. Dakdouki b, Khalil I. El-Chammas c, Shaker Eid d, George F. Araj e, Souha S. Kanj f,* a Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA b Hammoud Hospital, Sidon, Lebanon c Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon d Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon e Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon f Division of Infectious Diseases, American University of Beirut Medical Center, Cairo Street, PO Box 113-6044, Hamra 110 32090, Beirut, Lebanon Received 10 October 2006; accepted 11 December 2006 Corresponding Editor: William Cameron, Ottawa, Canada KEYWORDS Summary Neutropenic fever; Objectives: Previous studies from Lebanon have shown Gram-negative organisms to be the Bacteremia; predominant agents in febrile neutropenic patients. The objective of this study was to evaluate Gram-negative infection; the most current epidemiological trends among patients with neutropenic fever. Lebanon Methods: This prospective observational cohort study, the largest to date in the country, was conducted at the American University of Beirut Medical Center between January 2001 and December 2003, with the objective of describing the characteristics of patients with neutropenic fever and to assess temporal trends. Results: We included 177 episodes of neutropenic fever. The most common underlying malignancy was lymphoma (42.4%). Gastrointestinal and abdominal infections were predominant (31.6%) and 23.7% of cases represented fever of unknown origin.
[Show full text]
Management of Febrile Neutropenia in Children: Current Approach and Challenges Parameswaran Anoop1, Channappa N Patil2
REVIEW ARTICLE Management of Febrile Neutropenia in Children: Current Approach and Challenges Parameswaran Anoop1, Channappa N Patil2 ABSTRACT Neutropenia can result from failure, infiltration, or suppression of the bone marrow due to nonmalignant disorders, cancers, chemotherapy, radiation, or a combination of these. Febrile neutropenia (FN) is a hemato-oncological emergency and is an important cause of death in immunocompromised children. Prompt and stepwise management of FN helps to minimize the morbidity and mortality considerably. In resource-constraint countries, additional challenges can be encountered during the treatment of fever in neutropenic patients. In India, many children with FN are initially treated at regional centers and later referred to tertiary units if needed. Pediatricians should hence be familiar with the treatment algorithm and specific issues related to the management of FN. Keywords: Antibiotic resistance, Febrile neutropenia, Risk, Supportive care. Pediatric Infectious Disease (2020): 10.5005/jp-journals-10081-1257 INTRODUCTION 1,2Department of Hemato-oncology, Apollo Hospitals, Bengaluru, Low neutrophil count is an important cause for septicemic deaths Karnataka, India in children globally. In hemato-oncological practice, febrile Corresponding Author: Parameswaran Anoop, Department of neutropenia (FN) is the most commonly encountered medical Hemato-oncology, Apollo Hospitals, Bengaluru, Karnataka, India, emergency. In India and many resource-poor countries, there is Phone: +91 9035018115, e-mail: [email protected] a relatively high incidence of bacterial, fungal, and opportunistic How to cite this article: Anoop P, Patil CN. Management of Febrile infections. The emergence of antimicrobial drug resistance Neutropenia in Children: Current Approach and Challenges. Pediatr Inf further compounds this problem. Thus, the management of FN Dis 2020;2(4):135–139.
[Show full text]
Febrile Neutropenia Intro Hi Everyone, My Name Is Dr. Chris
PedsCases Podcast Scripts This is a text version of a podcast from Pedscases.com on “Febrile Neutropenia.” These podcasts are designed to give medical students an overview of key topics in pediatrics. The audio versions are accessible on iTunes or at www.pedcases.com/podcasts. Febrile Neutropenia Developed by Chris Novak, and Dr. Bev Wilson for PedsCases.com. January 27, 2016 Intro Hi everyone, my name is Dr. Chris Novak. I’m a pediatric resident at the Stollery Children’s Hospital at the University of Alberta. Today’s podcast is designed to give an organized approach to febrile neutropenia in children. This podcast was developed with Dr. Bev Wilson, a pediatric oncologist and Professor at the University of Alberta and in Edmonton, Alberta. Let’s start with a clinical case. You are on an emergency medicine rotation in a peripheral hospital. You sign up to see Hakim, a 4-year-old male with a fever, measured 38.9oC at triage. Upon entering the room Hakim’s parents quickly tell you that he is being treated with outpatient chemotherapy for acute lymphoblastic leukemia, and that his oncology team told the family to go to emergency immediately if he develops a fever. You recognize that Hakim is at risk for febrile neutropenia. What do you need to consider when assessing this patient? What time-sensitive investigations and therapies need to be initiated? We will come back to the case of Hakim as an example as we go through the podcast. In the neutropenic patient, a fever can be an ominous sign of a serious infection.
[Show full text]
Febrile Neutropenia
CLINICAL PROCEDURE FEBRILE NEUTROPENIA TARGET AUDIENCE All clinical staff including medical, nursing and pharmacy. PURPOSE This document incorporates the key requirements for a hospital neutropenic fever (NF) guideline/pathway. The document includes evidenced based recommendations for the assessment and management of NF and sepsis. 1. Consensus definitions 2. Investigations 3. Initial antibiotic therapy based on severity 4. Ongoing antibiotic therapy 5. Prophylaxis 6. Antiviral and antifungal therapy 7. Management of the low risk patient with neutropenic fever MANAEMENT OF NEEUTROPENIC FEVER All patients with neutropenic fever as defined above should be initially assessed for the presence of systemic cardiovascular compromise, and whether they are considered high- or low-risk for medical complications. These factors determine the initial choice of antibiotic therapy, time to administration of antibiotics, the likely duration of admission and whether ambulatory care may be considered (see Figure 1). Recently, evidence has demonstrated that prompt administration of antibiotics is associated with a measureable decrease in mortality such that now, time to first dose antibiotic has been included in international sepsis guidelines (Kumar et al., 2006) (Dellinger et al., 2008) Importantly, neutropenic patients can present septic with haemodynamic compromise without fever (if elderly, or on steroids) in which case there should be no delay in treatment while evaluating for further fever. All patients presenting with fever following chemotherapy should be managed as if they have neutropenic fever and receive empiric antibiotics without waiting for laboratory confirmation of neutrophil count (expert opinion). This management may then be modified if neutrophil count and function are confirmed to be adequate. Optimal empiric management will be informed by the patient’s presenting clinical status.
[Show full text]
Neutropenia (Low White Blood Count)
Patient & Family Guide 2018 Neutropenia (Low White Blood Count) www.nscancercare.ca Neutropenia (Low White Blood Count) Your blood is made up of many solid particles, cells and fluid. One type of cell is your white blood cells. Neutrophils (new-tro-phil-s) are a specific type of white blood cell. White blood cells fight infection and neutrophils start the fight. Neutropenia (new-tro-pee-ne-a) happens when you do not have enough neutrophils. If you have this problem you are neutropenic. You are at a greater risk of infection when you do not have enough neutrophils. The lower your white blood cell count (WBC) the higher your risk of infection. It is very important that infections are caught early and treated quickly. A normal white blood cell count is between 4,500 -11,000 (or 4.5-11). Your white blood cell count may go as low as 100 (or .1). Absolute Neutrophil Count (ANC) is the term used to describe the number of neutrophils in your blood. A normal ANC is about 2500-7500 (or 2.5-7.5). What causes neutropenia? Neutrophils, like other blood cells, are made in your bone marrow and released into the blood stream. Some cancer treatments, certain types of cancer and other illnesses can affect the bone marrow so not enough neutrophils are made. Stem Cell Transplant and cancer systemic therapy (sometimes called chemo) may lower your white blood cell count temporarily. Usually, your blood counts will be at their lowest 10-14 days after cancer treatment. Usually, your counts will return to normal over the next 2 weeks.
[Show full text]
Piperacillin-Tazobactam Plus Amikacin As an Initial Empirical Therapy of Febrile Neutropenia in Paediatric Cancer Patients Hamidah A, Rizal a M, Nordiah a J, Jamal R
Original Article Singapore Med J 2008; 49 (1) : 26 Piperacillin-tazobactam plus amikacin as an initial empirical therapy of febrile neutropenia in paediatric cancer patients Hamidah A, Rizal A M, Nordiah A J, Jamal R ABSTRACT Conclusion: This study suggests that Introduction: We evaluated piperacillin- piperacillin-tazobactam plus amikacin presents tazobactam in association with amikacin in the a satisfactory efficacy and a good tolerance as initial empirical therapy of febrile neutropenic initial empirical therapy for febrile neutropenic children. children. Methods: An open-labelled, non-randomised, Keywords: amikacin, childhood cancer, febrile prospective trial to assess the efficacy and neutropenia, piperacillin-tazobactam safety of this association was conducted from Singapore Med J 2008; 49(1): 26-30 June 1, 2001 to December 31, 2002. Children and adolescents were treated for a INTRODUCTION haematological malignancy or a primary, Empirical broad-spectrum antibiotic therapy remains the refractory or relapsed solid tumour, and cornerstone of treatment for febrile neutropenic patients. presented with febrile neutropenia. Patients This approach has been shown to significantly reduce the received intravenous piperacillin-tazobactam morbidity and mortality from severe infection in particular (90 mg/kg/dose every eight hours) plus a single gram-negative bacteraemias.(1) The guidelines of the daily dose of amikacin at 15 mg/kg/day, Infectious Diseases Society of America (IDSA) published maximum 250 mg. If fever persisted, second- in 2002 recommend either monotherapy with cefepime, line therapy with carbapenem was ceftazidime, a carbapenem, or duotherapy with an Department of administered. Teicoplanin was added for gram- antipseudomonal ß-bactam antibiotic in combination with Paediatrics, Hospital Universiti positive isolates or for unremitting fever after an aminoglycoside as empirical antimicrobial therapy in Kebangsaan Malaysia, (2) Faculty of Medicine, 48 hours, if clinically indicated.
[Show full text]
Guidelines in the Management of Febrile Neutropenia for Clinical Practice
PERSPECTIVES IN FEBRILE NEUTROPENIA REFERENCES prevention of febrile neutropenia in patients with epithelial ovarian carcinoma—a cost- 1. Tangka FK, Trogdon JG, Richardson LC, Howard D, Sabatino SA, Finkelstein EA. effectiveness analysis. Int J Gynecol Cancer. 2007;17(5):1019-1024. Cancer treatment cost in the United States: has the burden shifted over time? Cancer. 6. Vanderpuye-Orgle J, Sexton Ward A, Huber C, Kamson C, Jena AB. Estimating the social 2010;116(14):3477-3484. doi: 10.1002/cncr.25150. value of G-CSF therapies in the United States. Am J Manag Care®. 2016;22(10):e343-e349. 2. Dinan MA, Hirsch BR, Lyman GH. Management of chemotherapy-induced neutrope- 7. Neupogen [prescribing information]. Thousand Oaks, CA: Amgen, Inc; 1991. nia: measuring quality, cost, and value. J Natl Compr Canc Netw. 2015;13(1):e1-e7. 8. Neulasta [prescribing information]. Thousand Oaks, CA: Amgen, Inc; 2002. 3. Wang XJ, Lopez SE, Chan A. Economic burden of chemotherapy-induced febrile 9. Granix [prescribing information]. North Wales, PA: Teva Pharmaceuticals USA, Inc; neutropenia in patients with lymphoma: a systematic review. Crit Rev Oncol Hematol. 2012. 2015;94(2):201-212. doi: 10.1016/j.critrevonc.2014.12.011. 10. Zarxio [prescribing information]. Princeton, NJ: Sandoz Inc; 2015. 4. Eldar-Lissai A, Cosler LE, Culakova E, Lyman GH. Economic analysis of prophy- 11. Sierra J, Szer J, Kassis J, et al. A single dose of pegfilgrastim compared with daily lactic pegfilgrastim in adult cancer patients receiving chemotherapy. Value Health. filgrastim supporting neutrophil recovery in patients treated for low-to-intermediate risk 2008;11(2):172-179.
[Show full text]
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Myeloid Growth Factors
NCCN Guidelines Index MGF Table of Contents Discussion NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines® ) Myeloid Growth Factors Version 2.2013 NCCN.org Continue Version 2.2013, 08/02/13 © National Comprehensive Cancer Network, Inc. 2013, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Version 2.2013 Panel Members NCCN Guidelines Index MGF Table of Contents Myeloid Growth Factors Discussion * Jeffrey Crawford, MD/Chair †‡ Susan Hudock, PharmD å Lee S. Schwartzberg, MD † ‡ Þ Duke Cancer Institute The Sidney Kimmel Comprehensive St. Jude Children's Research Hospital/ Cancer Center at Johns Hopkins The University of Tennessee Health Science James Armitage, MD † x Center- The West Clinic UNMC Eppley Cancer Center at Dwight D. Kloth, PharmD å å The Nebraska Medical Center Fox Chase Cancer Center Sepideh Shayani, PharmD City of Hope Comprehensive Cancer Center Lodovico Balducci, MD † ‡ David J. Kuter, MD, DPhil † ‡ Moffitt Cancer Center Massachusetts General David P. Steensma, MD†‡Þ Hospital Cancer Center Dana-Farber/Brigham and Women’s Pamela Sue Becker, MD, PhD ‡ Þ x Cancer Center Fred Hutchinson Cancer Research Center/ Gary H. Lyman, MD, MPH † ‡ å Seattle Cancer Care Alliance Duke Cancer Institute Mahsa Talbott, PharmD Vanderbilt-Ingram Cancer Center Douglas W. Blayney, MD † Brandon McMahon, MD ‡ Stanford Cancer Institute Robert H. Lurie Comprehensive Cancer Saroj Vadhan-Raj, MD † Þ Center of Northwestern University The University of Texas Spero R. Cataland, MD ‡ MD Anderson Cancer Center The Ohio State University Comprehensive Hope S. Rugo, MD † ‡ x Cancer Center - James Cancer Hospital UCSF Helen Diller Family Peter Westervelt, MD, PhD † Siteman Cancer Center at Barnes- and Solove Research Institute Comprehensive Cancer Center Jewish Hospital and Washington University School of Medicine Mark L.
[Show full text]
Ceftolozane-Tazobactam Treatment of Hypervirulent Multidrug Resistant Pseudomonas Aeruginosa Infections in Neutropenic Patients
microorganisms Case Report Ceftolozane-Tazobactam Treatment of Hypervirulent Multidrug Resistant Pseudomonas aeruginosa Infections in Neutropenic Patients Paolo E. Coppola 1, Paolo Gaibani 2, Chiara Sartor 1, Simone Ambretti 2, Russell E. Lewis 3,4, Claudia Sassi 5,6, Marco Pignatti 6,7, Stefania Paolini 1, Antonio Curti 1, Fausto Castagnetti 1,6, Margherita Ursi 1, Michele Cavo 1,6 and Marta Stanzani 1,* 1 Institute of Hematology “Seràgnoli”, IRCCS-Azienda Ospedaliero Policlinico Sant’Orsola-Universitaria di Bologna, 40138 Bologna, Italy; [email protected] (P.E.C.); [email protected] (C.S.); [email protected] (S.P.); [email protected] (A.C.); [email protected] (F.C.); [email protected] (M.U.); [email protected] (M.C.) 2 Microbiology, IRCCS-Azienda Ospedaliero Policlinico Sant’Orsola-Universitaria di Bologna, 40138 Bologna, Italy; [email protected] (P.G.); [email protected] (S.A.) 3 Infectious Diseases, IRCCS-Azienda Ospedaliero Policlinico Sant’Orsola-Universitaria di Bologna, 40138 Bologna, Italy; [email protected] 4 Department of Medical and Surgical Sciences (DIMEC)- Università di Bologna, Alma Mater Studiorum, 40138 Bologna, Italy 5 Radiology, IRCCS-Azienda Ospedaliero Policlinico Sant’Orsola-Universitaria di Bologna, 40138 Bologna, Italy; [email protected] 6 Department of Diagnostic and Experimental Medicine Specialty (DIMES)- Università di Bologna, Alma Mater Studiorum, 40138 Bologna, Italy; [email protected] 7 Plastic Surgery, IRCCS-Azienda Ospedaliero Policlinico Sant’Orsola-Universitaria di Bologna, 40138 Bologna, Italy * Correspondence: [email protected] Received: 12 November 2020; Accepted: 11 December 2020; Published: 21 December 2020 Abstract: The eﬀectiveness of ceftolozane/tazobactam for the treatment of infections in neutropenic patients caused by hypervirulent multidrug-resistant (MDR) Pseudomonas aeruginosa has not been previously reported.
[Show full text]
Treatment of Fever and Neutropenia in Hematology/Oncology and Hematopoietic Cell Transplant Patients
TREATMENT OF FEVER AND NEUTROPENIA IN HEMATOLOGY/ONCOLOGY AND HEMATOPOIETIC CELL TRANSPLANT PATIENTS Purpose Scope Definitions Goals Initial Assessment Recommended Treatment Management of Persistent Fever Duration of Therapy References/footnotes Figure 1 – Initial Empiric Treatment Appendix 1 – Figure 2 – Antibiotic De-escalation of Febrile Neutropenia Pediatric Oncology triage I. PURPOSE: This algorithm describes the evidence-based approach for the management of high-risk hematology/oncology and hematopoietic cell transplant (HCT) patients with fever and neutropenia. II. SCOPE: This guideline outlines the antibiotic management of the first neutropenic fever and persistent fever. III. DEFINITIONS: A. Neutropenia: Absolute neutrophil count (ANC) <500 cells/mm3 or <1000 cells/mm3 with a predicted decline to <500/mm3 based on recent chemotherapy administration B. Fever: Single temperature (oral or axillary) ≥38.3°C (101°F) or two temperatures (oral or axillary) of 38.0°C (100.4°F) at least 1 hour apart *NOTE: Oral temperatures are preferred for increased accuracy. Additional degrees should not be added to axillary temperatures. Rectal temperature should not be obtained in neutropenic patients. IV. GOALS: A. To ensure febrile neutropenia patients receive appropriate empiric antibiotics and appropriate cultures are obtained B. To ensure all patients have their first dose of antibiotics initiated within 30 minutes of fever or upon arrival to the emergency department (ED) V. INITIAL ASSESSMENT A. Optimally obtain both aerobic and anaerobic blood cultures from all lumens of ALL central venous catheters and peripheral blood culture before initiation of antimicrobials. In pediatric patients with central access, peripheral cultures are not required (aerobic blood cultures only can be obtained for follow up cultures).
[Show full text]
Febrile Neutropenia
JAMA ONCOLOGY PATIENT PAGE Febrile Neutropenia Febrile neutropenia is a common complication in patients undergoing anticancer treatments. What Is Neutropenia? What is neutropenia? A neutrophil is a specific type of white blood cell (immune cell) that Neutropenia is when there is a low number of neutrophils in the blood. plays an important role as the body’s first line of defense. The neu- Normal blood cells Neutropenia under the microscope (low neutrophil count) trophils usually make up about half to two-thirds of all white blood Red blood cells and protect against bacterial infections. Patients receiving can- cells Platelet cer chemotherapy (and potentially other) treatments can experi- ence a temporary reduction in their white blood cell counts as a di- rect result of their treatment. In adults, the lower limit of normal neutrophils is 1500 neutrophils per microliter of blood; any num- Neutrophil ber below that is considered neutropenia. Neutropenia grows more severe as the absolute neutrophil count declines from 1500 to 1000 or even below 500. Absolute neutrophil count (ANC) ANC less than 1500 per microliter What Is Febrile Neutropenia? greater than 1500 per microliter of blood Febrile neutropenia refers to the occurrence of a fever during a pe- of blood riod of significant neutropenia. When a patient has neutropenia, his What is febrile neutropenia? or her risk of infection may be higher than normal, and the severity Fever (temperature greater IV antibiotics ofagiveninfectionmaybehigheralso.Infectionscanresultfromtrans- than 100.3ºF) mission of infectious agents between people or as a result of organ- plus isms that live in the mouth, gut, or on the skin but do not normally ANC less than 500 per microliter causeillnessbecausethehealthyimmunesystemkeepsthemincheck.
[Show full text]