DOCSLIB.ORG

Management of Infection and Febrile Neutropenia in Patients with Solid Cancer

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Management of Infection and Febrile Neutropenia in Patients with Solid Cancer Clin Transl Oncol DOI 10.1007/s12094-015-1442-4 CLINICAL GUIDES IN ONCOLOGY Management of infection and febrile neutropenia in patients with solid cancer 1 2 3 1 4 5 6 7 J. A. Virizuela • J. Carratala` • J. M. Aguado • D. Vicente • M. Salavert • M. Ruiz • I. Ruiz • F. Marco • 3 8 2,9 10 11 12 M. Lizasoain • P. Jime´nez-Fonseca • C. Gudiol • J. Cassinello • A. Carmona-Bayonas • M. Aguilar • J. J. Cruz13 Received: 2 October 2015 / Accepted: 26 October 2015 Ó Federacio´n de Sociedades Espan˜olas de Oncologı´a (FESEO) 2015 Abstract An expert group from the Spanish Society of vaccines, measures to control infection through vascular Infectious Diseases and Clinical Microbiology (SEIMC, catheters, and preventing infection in light of certain sur- for its acronym in Spanish) and the Spanish Society of gical maneuvers. The following is a revision of the criteria Medical Oncology (SEOM, for its acronym in Spanish) for febrile neutropenia management and the use of colony- have reviewed the main aspects to be considered when stimulating factors and closes with several guidelines for evaluating patients with solid cancer and infectious com- treating the cancer patient with serious infection. The plications contained in this article. Recommendations have, document concludes with a series of measures to control therefore, been put forth regarding the prophylaxis of the hospital infection. most prevalent infections in these patients, the use of Keywords Cancer Á Febrile neutropenia Á Infection Á Prophylaxis Á Risk factors Jordi Carratala`, Jose´ Marı´a Aguado, Miguel Salavert, Francesc Marco, Manuel Lizasoain, Carlota Gudiol, Manuela Aguilar: Members of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). Juan Antonio Virizuela, David Vicente, Maribel Ruiz, Paula Jime´nez Fonseca, Javier Cassinello, Alberto Carmona-Bayonas, Juan Jesu´s Cruz: Members of the Spanish Society of Medical Oncology (SEOM). 8 & J. A. Virizuela Servicio de Oncologı´aMe´dica, Hospital Universitario [email protected] Central de Asturias, Oviedo, Asturias, Spain 9 Institut Catala` d’Oncologia, Barcelona, Spain 1 Servicio de Oncologı´aMe´dica, Hospital Universitario Virgen 10 de Macarena, Avda. Doctor Fedriani, 3, 41071 Seville, Spain Servicio de Oncologı´aMe´dica, Hospital Universitario de Guadalajara, Guadalajara, Spain 2 Servicio de Enfermedades Infecciosas, Hospital Universitari 11 de Bellvitge-IDIBELL, Universitat de Barcelona, Barcelona, Servicio de Hematologı´a y Oncologı´aMe´dica, Hospital Spain General Universitario Morales Meseguer, Murcia, Spain 12 3 Unidad de Enfermedades Infecciosas, Hospital Universitario Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Madrid, Spain Virgen del Rocı´o, Seville, Spain 13 4 Unidad de Enfermedades Infecciosas, Hospital Universitari i Servicio de Oncologı´aMe´dica, Hospital Clı´nico Polite`cnic La Fe, Valencia, Spain Universitario de Salamanca, Salamanca, Spain 5 Servicio de Oncologı´aMe´dica, Hospital Universitari Vall d’Hebron, Barcelona, Spain 6 Unidad de Enfermedades Infecciosas, Hospital Universitari Vall d’Hebron, Barcelona, Spain 7 Laboratori de Microbiologia, Centre de Diagno`stic Biome`dic (CDB), ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clı´nic, Universitat de Barcelona, Barcelona, Spain 123 Clin Transl Oncol Introduction gynecological checkup is also advised, as is screening for the human papilloma virus (HPV). Over the course of the last two decades, substantial head- The initial microbiological assessment is aimed at way has been made in the treatment of the cancer patient. screening for the most common chronic or latent infections Undoubtedly, one of the most outstanding advances has that may recrudesce in the event of immunosuppression been the decrease in infection-related morbimortality due and will depend on the type of chemotherapy administered to the progress achieved in preventing and treating these and on the specific risk of immunosuppression in each infections, as well as in shortening the period of neu- person. In general, depending on the chemotherapy, dura- tropenia, thanks to the use of hematopoietic growth factors. tion, immunosuppressant probability, and on the type of Despite these advances, infectious complications con- patient and their perspectives for survival, it is advisable to tinue to be one of the main causes of death in oncological know the serology for: (1) hepatitis A, B, and C virus patients. These individuals are subject to greater risk of (HAV, HBV, and HCV); (2) varicella zoster virus (VZV), certain infections being reactivated and are more likely to and (3) human immunodeficiency virus (HIV). Likewise, suffer nosocomial pathogens as a consequence of surgeries, tuberculosis (TBC) must be ruled out in the event of any the use of venous or urinary catheters and other devices, as uncertainty in this regard, people in contact with TBC or at well as the procedures they undergo. The emergence of risk populations, such as institutionalized individuals. multiresistant microorganisms in recent years has compli- There are regional diseases that must be taken into con- cated the issue of antibiotherapy in this population even sideration in patients from certain geographical areas further. Moreover, the growing use of new monoclonal (Table 1). antibodies and biological therapies has incremented the possibility of certain serious infections in these patients. While there are numerous clinical guidelines addressing Prevention the hematologic patient, few focus specifically on people with solid tumors. Experts from the Spanish Society of Vaccination Infectious Diseases and Clinical Microbiology (SEIMC, for its acronym in Spanish) and the Spanish Society of Table 2 contains the agents (obligatorily inactivated) to be Medical Oncology Me´dica (SEOM, for its acronym in used in these cases [1]. Vaccines containing attenuated live Spanish) have, therefore, undertaken to elaborate this microorganisms such as the rotavirus, 3-in-1 viral vaccine document, in which the pertinent information currently (measles, mumps, rubella), and chicken pox are con- available has been reviewed and recommendations based traindicated during chemotherapy [2]. on the best evidence available have been put forth, in the Patients with active solid tumors and those undergoing hope that they will help oncologists and specialists in chemotherapy must be vaccinated yearly for the flu [2]. It infectious medicine in their daily clinical practice and urge is recommended that they be immunized against pneumo- them to manage these patients together, in pursuit of coccus in accordance with the guidelines for immunode- optimal care for cancer patients with infectious disease. pressed patients. Depending on the aforementioned characteristics (type of chemotherapy, duration, clinical status), a booster dose Initial evaluation should be given against tetanus and diphtheria. Those who have not been protected against pertussis should be given The initial evaluation of cancer patients undertakes to the diphtheria, tetanus, and acellular pertussis vaccine detect active or latent infections at risk for reactivation in (DTaP). Likewise, HPV, meningococus, and HAV inocu- individuals with solid cancer who are to undergo poten- lations must be administered whenever there is a specific tially immunosuppressant treatment. indication. Immunization against HBV must be contem- The clinical assessment should include: (1) history of plated in unprotected individuals, after assessing their infectious diseases that may have remained latent and serological and clinical status. reactivate in the event of immunosuppression; (2) full The previously indicated agents should be given prior to epidemiological history, including contacts with patients initiating chemotherapy. Inactivated vaccines should be with infectious disease, as well as with other immunode- administered at least 2 weeks before beginning treatment pressed individuals; (3) patient’s origin and any visits or (with the exception of the flu vaccine, which will be given trips to countries outside our geographical area with yearly, even during chemotherapy), whereas attenuated endemic diseases that could be revived, and (4) history of live vaccines must be administered at least 4 weeks prior to possible drug reactions to antimicrobials. In women, a commencing treatment [3]. 123 Clin Transl Oncol Table 1 Regional or imported diseases by geographical area of procedence Country of procedence Probable Screening technique microorganism Mexico, Panama, Venezuela, Guatemala, or Southern US Histoplasma Serology capsulatum Southern US, Mexico, Guatemala, Honduras, Nicaragua, Argentina, Paraguay, Venezuela, Coccidioides immitis Serology and Colombia Caribbean, Southern Japan, Central and South America, Sub-Saharan Africa HTLV-I-II Serology Mexico, Central America, or Southern Cone (Chile, Argentina, Bolivia, Brazil, Paraguay) Trypanosoma cruzi Two serological techniques Tropical and subtropical regions, including Southern US Strongyloides Agar technique stercoralis Feces culture Serology Endemic areas for malaria during the last 2–5 years: asymptomatic parasitemias should be Plasmodium sp PCR ruled out Thick blood film HTLV-I-II: human T cell lymphotropic virus types I and II; PCR: polymerase chain reaction Table 2 Recommended vaccines for adults with solid tumors Vaccine Recommendation Regimen Pneumococcus Recommended 1st dose (VNC13) at diagnosis prior to treatment; subsequent doses: one VNP23 dose at 8 weeks Influenza Recommended Yearly
Load more

Recommended publications
  • Infection Control for Neutropenic Cancer Patients : the Libraryuse of Prophylactic Antibiotics Lecture Author Jean A
    Infection control for neutropenic cancer patients : the Libraryuse of prophylactic antibiotics Lecture author Jean A. Klastersky Onlineby Institut Jules Bordet,© Université Libre de Bruxelles (ULB) Brussels, Belgium ESCMID Complications and mortality associated with febrile neutropenia Library No Bacteremia Bacteremia Total ComplicationsLectureDeaths Total Complications Deaths author Solid tumors 784 60 (8 %) 25 135 30 (22 %) 17 Onlineby (3 %) (13 % ) © Hematological cancer 859 111 (13 %) 32 364 76 (21 %) 32 (4 %) (9 %) ESCMID J. Klastersky et al., 2007 2 Complications associated with febrile neutropenia Library Hypotension : systolic blood pressure less than 90 mmHg or need for pressor support to maintain blood pressure Respiratory failure : arterial oxygen pressure less than 60mmHg while breathing room air or needLecture for mechanical ventilation Disseminated intravascular coagulation Confusion or altered mental state author Congestive cardiac failure seen on chest X-ray and requiring treatment Onlineby Bleeding severe enough to require© transfusion Arrhythmia or ECG changes requiring treatment Renal failure requiring investigation and/or treatment with IV fluids, dialysis, or any other intervention ESCMID J. Klastersky et al., 2000 3 Cost of febrile neutropenia Library Initial hospitalization Initial hospitalization plus all downstreamLecture neutropenia care author 2.010 $ Onlineby 14.407 $ © ESCMID D. Weyckler et al., 2008 4 Use of oral antibiotics in protected units environment : clinical effectiveness and role in the emergence
    [Show full text]
  • 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]
  • Vancomycin-Resistant Enterococci Colonization in Patients with Hematological Malignancies: Screening and Its Cost-Effectiveness
    Vancomycin-resistant enterococci colonization in patients with hematological malignancies: screening and its cost-effectiveness Gedik Habip1, Şimşek Funda1, Kantürk Arzu1, Yıldırmak Taner1, Arıca Deniz2, Aydın Demet2, Yokuş Osman2, Demirel Naciye2 1. Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, Istanbul 2. Department of Hematology, Ministry of Health Okmeydanı Training and Research Hospital, Istanbul Abstract: Background and objective: We evaluated the rates of vancomycin-resistant enterococci (VRE) colonization and VRE- related bacteremia in patients with hematological malignancies in terms of routine screening culture and its cost-effective- ness. Materials and Methods: All patients of the hematology department who were older than 14 years of age and who devel- oped at least one febrile neutropenia episode during chemotherapy for hematological cancers between November 2010 and November 2012 were evaluated retrospectively. Results: We retrospectively analyzed 282 febrile episodes in 126 neutropenic patients during a two-year study period. The study included 65 cases in the first study-year and 78 cases in the second study-year. The numbers of colonization days and colonized patient were748 days of colonization in 29 patients (44%) in the first study-year and 547 colonization days in 21 patients (26%) in the second study-year, respectively. Routine screening culture for VRE cost $4516,4 (427 cultures) in the first study-year, $5082,7 (504 cultures) in the second study-year depending on the number of patients and their length of stay. Conclusion: In line with our study results, routine screening of hematological patients for VRE colonization is not cost- effective. Routine surveillance culture for VRE should be considered with respect to the conditions of health care setting.
    [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]
  • Neonatal Leukopenia and Thrombocytopenia
    Neonatal Leukopenia and Thrombocytopenia Vandy Black, M.D., M.Sc., FAAP March 3, 2016 April 14, 2011 Objecves • Summarize the differenHal diagnosis of leukopenia and/or thrombocytopenia in a neonate • Describe the iniHal steps in the evaluaon of a neonate with leukopenia and/or thrombocytopenia • Review treatment opHons for leukopenia and/ or thrombocytopenia in the NICU Clinical Case 1 • One day old male infant admiUed to the NICU for hypoglycemia and a sepsis rule out • Born at 38 weeks EGA by SVD • Birth weight 4 lbs 13 oz • Exam shows a small cephalohematoma; no dysmorphic features • PLT count 42K with an otherwise normal CBC Definions • Normal WBC count 9-30K at birth – Mean 18K • What is the ANC and ALC – <1000/mm3 is abnormal – 6-8% of infants in the NICU • Normal platelet count: 150-450,000/mm3 – Not age dependent – 22-35% of infants in the NICU have plts<150K Neutropenia Absolute neutrophil count <1500/mm3 Category ANC* InfecHon risk • Mild 1000-1500 None • Moderate 500-1000 Minimal • Severe <500 Moderate to Severe (Highest if <200) • Recurrent bacterial or fungal infecHons are the hallmark of symptomac neutropenia! • *ANC = WBC X % (PMNs + Bands) / 100 DefiniHon of Neutropenia Black and Maheshwari, Neoreviews 2009 How to Approach Cytopenias • Normal vs. abnormal (consider severity) • Malignant vs. non-malignant • Congenital vs. acquired • Is the paent symptomac • Transient, recurrent, cyclic, or persistent How to Approach Cytopenias • Adequate vs. decreased marrow reserve • Decreased producHon vs. increased destrucHon/sequestraon Decreased neutrophil/platelet producon • Primary – Malignancy/leukemia/marrow infiltraon – AplasHc anemia – Genec disorders • Secondary – InfecHous – Drug-induced – NutriHonal • B12, folate, copper Increased destrucHon/sequestraon • Immune-mediated • Drug-induced • Consumpon à Hypersplenism vs.
    [Show full text]
  • Enterococcal Bacteremia in Febrile Neutropenic Children and Adolescents with Underlying Malignancies, and Clinical Impact of Vancomycin Resistance
    Infection (2019) 47:417–424 https://doi.org/10.1007/s15010-018-1260-z ORIGINAL PAPER Enterococcal bacteremia in febrile neutropenic children and adolescents with underlying malignancies, and clinical impact of vancomycin resistance Kil‑Seong Bae1,2 · Ju Ae Shin1 · Seong koo Kim1,3 · Seung Beom Han1,2 · Jae Wook Lee1,3 · Dong‑Gun Lee2,3,4 · Nack‑Gyun Chung1,3 · Bin Cho1,3 · Dae Chul Jeong1,2 · Jin Han Kang1,2 Received: 28 August 2018 / Accepted: 15 December 2018 / Published online: 19 December 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Purpose Enterococci are a common cause of bacteremia in immunocompromised patients. Although the increase of van- comycin-resistant enterococci (VRE) makes appropriate antibiotic therapy difficult, clinical characteristics of enterococcal bacteremia and the impact of VRE infection on outcomes have rarely been reported in immunocompromised children. Methods We enrolled children and adolescents (< 19 years of age) with underlying malignancies who were diagnosed with enterococcal bacteremia during febrile neutropenia between 2010 and 2017. Medical records of the enrolled children were retrospectively reviewed to evaluate the clinical characteristics of enterococcal bacteremia and impact of VRE infection on outcomes. Results Thirty-six episodes of enterococcal bacteremia were identified in 30 patients. VRE infection was identified in 11 epi- sodes (30.6%); the 7- and 30-day mortalities were 27.8% and 44.4%, respectively. Acute lymphoblastic leukemia (50.0%) and acute myeloid leukemia (30.6%) were the most common underlying disorders. Three (8.3%) of the patients were in complete remission, and palliative and reinduction chemotherapies were administered in 47.2% and 36.1% of episodes, respectively.
    [Show full text]
  • Neutropenia : an Analysis of the Risk Factors for Infection Steven Ira Rosenfeld Yale University
    Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 1980 Neutropenia : an analysis of the risk factors for infection Steven Ira Rosenfeld Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Recommended Citation Rosenfeld, Steven Ira, "Neutropenia : an analysis of the risk factors for infection" (1980). Yale Medicine Thesis Digital Library. 3087. http://elischolar.library.yale.edu/ymtdl/3087 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. NEUTROPENIA: AN ANALYSIS OF THE RISK FACTORS FOR INFECTION by Steven Ira Rosenfeld B.A. Johns Hopkins University 1976 A Thesis Submitted to The Yale University School of Medicine In Partial Fulfillment of the Requirements for the Degree of Doctor of Medicine 1980 Med Li^> Ya ABSTRACT The risk factors for infection were evaluated retrospectively in 107 neutropenic patients without underlying malignancy or cyto¬ toxic drug therapy. Neutrophil count was an independent risk factor for infection, with the incidence of infection increasing as the neutrophil count decreased. The critical neutrophil count, below which the incidence of infection was significantly increased was 250/mnr*, (p<.001). Eighty five percent of the <250 group entered with, or developed infection. Additional risk factors for infection included increased duration of neutropenia, age less than 1 year old, male sex, hypogammaglobulinemia, and recent antibiotic therapy.
    [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]
  • Neutropenia and Risk for Infection
    WHAT YOU NEED TO KNOW NEUTROPENIA AND RISK FOR INFECTION WHAT IS NEUTROPENIA? Neutropenia, pronounced noo-troh-PEE-nee-uh, is a decrease in the number of white blood cells. These cells are the body’s main defense against infection. Neutropenia is common after receiving chemotherapy and increases your risk for infections. Why does chemotherapy cause neutropenia? These cancer-fighting drugs work by killing fast-growing cells in the body—both good and bad. These drugs kill cancer cells as well as healthy white blood cells. How do I know if I have neutropenia? Your doctor or nurse will tell you. Because neutropenia is common after receiving chemotherapy, your doctor may draw some blood to look for neutropenia. When will I be most likely to have neutropenia? Neutropenia often occurs between 7 and 12 days after you receive chemotherapy. This period can be different depending upon the chemotherapy you get. Your doctor or nurse will let you know exactly when your white blood cell count is likely to be at its lowest. You should carefully watch for signs and symptoms of infection during this time. How can I prevent neutropenia? There is not much you can do to prevent neutropenia from occurring, but you can decrease your risk for getting an infection while your white blood cell count is low. National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control Made possible by a CDC Foundation partnership with Amgen How can I prevent an infection? What are the In addition to receiving treatment from your doctor, the signs and symptoms following suggestions can help prevent infections: of an infection? • Clean your hands frequently.
    [Show full text]