Febrile neutropenia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: FN, febrile leukopenia, neutropenic fever, neutropenic fever syndrome, neutropenic sepsis, hot and low, F and N, a hot leuk

Overview

Febrile neutropenia is defined as one oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) for over one hour. Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells/mm3 or an ANC that is expected to become less than 500 cells/mm3 over the next 48 hours. Profound neutropenia is defined as an ANC <100 cells/mm3. Patients with functional neutropenia have a qualitative abnormality of neutrophil functions despite a normal or elevated ANC, as seen in hematological malignancy, and are at increased risk of infections similarly to patients with low ANC.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Day 1: Initial Management of Patients With Febrile Neutropenia

Shown below is an algorithm depicting the day 1 initial management of patients with febrile neutropenia based on the clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America (IDSA).[1]

 
 
 
 
 
 
Characterize the clinical and laboratory findings:

Fever in cancer patients who are on chemotherapy

❑ Single oral temperature ≥38.3° C (101° F)
or
❑ Temperature ≥38° C (100.4° F) sustained for over one hour

with
❑ Reduced absolute neutrophil count (ANC)

ANC <500 cells/mm3
or
ANC that is expected to decrease to <500 cells/mm3 in the next 48 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the diagnosis of febrile neutropenia
POTENTIALLY LIFE THREATENING
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history (an assessment of risk for complications of severe infections):

❑ Infections and inflammation of

❑ Skin and soft-tissues:
Erythema
❑ Intravenous catheter site pain and/or swelling
Nodules
Rash
Swelling
Ulcers
Vesicles
❑ Central nervous system (meningitis and encephalitis):
Altered mental status
❑ Behavioral or personality change
Clumsiness and unsteady gait
❑ Decreased levels of consciousness
Delirium
Headache
Irritability
Lethargy
Neck stiffness
Phonophobia
Photophobia
Seizures
Vomiting
❑ Oral cavity and oropharynx:
Dental pain
Mouth ulcers
Neck pain
❑ Lungs (pneumonia):
Dyspnea
Fever (high grade) with sweating, chills, and rigor
Pleuritic chest pain
❑ Productive cough (greenish or yellow sputum)
❑ Rapid and shallow breathing
❑ Abdomen (neutropenic enterocolitis or clostridium difficile colitis):
Diarrhea
❑ Crampy lower abdominal pain
❑ Fever with chills
Nausea
Abdominal distension
❑ Urinary tract (urinary tract infection):
❑ Back, flank or groin pain
❑ Cloudy and foul-smelling urine
Dysuria
Extreme fatigue
Frequent urination
Hematuria
Night sweats
Nocturia
❑ Pain in the midline suprapubic region
Shaking chills and high spiking fever
Vomiting

❑ History of any co-morbid conditions:

Diabetes mellitus
Chronic obstructive lung disease

❑ Any recent exposure to infections
❑ Any current antibiotic prophylaxis
❑ Non infectious causes of fever

Blood transfusions
Uncontrolled cancer

❑ Any recent surgical procedures

❑ Any prior documentation of infections or pathogen colonization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient (an assessment of risk for complications of severe infections):

Dehydration
❑ Vital signs:

❑ Blood pressure: Look for hypotension (<90/50 mm Hg)
❑ Pulse rate: Look for tachycardia (>100 beats/min)
❑ Respiratory rate: Look for tachypnea (>20 breaths/min)
❑ Oxygen saturation: Look for decreased oxygen saturation (<90%)
❑ Temperature: Look for a single oral temperature ≥38.3° C (101° F) or a temperature ≥38° C (100.4° F) sustained for over one hour

❑ Signs of infections and inflammation at:

❑ Skin and soft-tissues:
Cellulitis
Ecthyma gangrenosum
Erythema
Erythema multiforme
Erythema, swelling and/or tenderness at sites of previous procedures in skin (example: bone marrow aspiration site)
Furuncles
❑ Intravenous catheter site erythema and/or tenderness
Mucositis
Nodules
Paronychia
Perianal fissures
Pilonidal disease
Rash
❑ Skin lesions with a necrotic center
Ulcers
Vesicles
❑ Central nervous system (meningitis and encephalitis):
Altered sensorium
Brudzinski's sign
Kernig's sign
Nuchal rigidity
❑ Personality changes
❑ Oral cavity and oropharynx:
❑ Dental cellulitis
❑ Peritonsillar cellulitis
Mouth ulcers
❑ Lungs (pneumonia):
❑ Bronchial breath sounds
Crackles
❑ Decreased breath sounds
❑ Dullness on percussion
Increased tactile fremitus
❑ Increased volume of whispered (vocal fremitus)
Rales
Rhonchi
❑ Abdomen (neutropenic enterocolitis or clostridium difficile colitis):
Abdominal distension
❑ Abdominal tenderness
❑ Urinary tract (urinary tract infection):
❑ Back or flank tenderness
❑ Discomfort or pain at the urethral meatus
❑ Suprapubic tenderness
❑ Perineum:
Erythema
Tender hemorrhoids
❑ Tenderness on palpation
Don't do digital rectal examination and rectal temperature recording (increased risk of traumatizing the fragile mucosa and introducing infections)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests (routine):

CBC with

❑ Differential leukocyte count
Platelet count

BMP
AST
ALT
Total bilirubin
❑ Blood cultures (at least 2 sets)

Central catheter1st set2nd set
❑ Present❑ From each lumen of existing central catheters❑ From a peripheral vein site
❑ Absent❑ From one separate venipuncture❑ From another separate venipuncture

❑ Urinalysis


Order additional tests (not routine and order if clinically indicated):

TestsClinical indications
❑ Urine cultureUrinary tract infection
❑ Urinary catheter in place
❑ Abnormal findings on urinalysis
❑ Chest X-rayRespiratory tract infection
❑ CT headCNS infection
❑ CT sinusesSinus infection
❑ CT abdomen❑ Infection of abdominal organs
❑ CT pelvis❑ Infection of pelvic organs
❑ Stool for clostridium difficile toxin assayDiarrhea
❑ Stool for bacterial pathogen cultures or for ova and parasiteDiarrhea following a history of recent travel
❑ CSF analysis and cultureMeningitis
❑ Skin aspiration or biopsy for cytological testing, gram staining, and cultureSkin infection
❑ Sputum analysis❑ Productive cough
Bronchoalveolar lavage and analysis❑ Infiltrations on chest imaging with an uncertain etiology
❑ Nasal wash or bronchoalveolar lavage and assays for viral detection❑ Respiratory infection during an outbreak or during winter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do a risk assessment using MASCC risk Index: (MANDATORY)
CharacteristicScore
❑ No or mild symptoms in patients following an episode of febrile neutropenia❑ 5
❑ Absence of hypotension with a systolic blood pressure >90 mmHg❑ 5
❑ No chronic obstructive pulmonary disease (active chronic bronchitis, emphysema, decrease in forced expiratory volumes, need for oxygen therapy and/or steroids and/or bronchodilators)❑ 4
❑ Solid tumor or hematologic malignancy with no previously demonstrated fungal infection or empirically treated suspected fungal infection❑ 4
❑ Absence of dehydration that requires parenteral fluids❑ 3
❑ Moderate symptoms in patients following an episode of febrile neutropenia❑ 3
❑ Outpatient status❑ 3
❑ Age <60 years❑ 2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk patients:

❑ MASCC score ≥21


or


❑ Expected brief neutropenia (≤7 days)
and/or
❑ Clinically stable
and/or

❑ Absence of comorbidities (neurological changes, gastrointestinal symptoms, underlying chronic lung disease, intravascular catheter infection, hemodynamic instability, hepatic insufficiency, or renal insufficiency)
 
High risk patients:

❑ MASCC score <21


or


❑ Expected prolonged neutropenia (>7 days)
and
❑ Profound neutropenia (ANC≤100 cells mm3)
and/or
❑ Clinically unstable (unbearable pain, altered mental status, or hypotension)
and/or
❑ Presence of comorbidities (neurological changes, gastrointestinal symptoms, underlying chronic lung disease, intravascular catheter infection, hemodynamic instability, hepatic insufficiency, or renal insufficiency)


Patients who do not strictly fulfill the criteria for being at low risk


Afebrile neutropenic patients with new signs or symptoms suggestive of infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer oral or IV empirical broad-spectrum antibiotic therapy (URGENT):

Ciprofloxacin + Amoxicillin-clavulanate
❑ In clinic or hospital setting

❑ Observe for 4-24 hours after drug administration
 
Hospitalize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider continuing with inpatient IV broad-spectrum antibiotics:

❑ Inability to tolerate oral medications
❑ Unavailabilty of telephone, transportation to hospital, caregiver
❑ Identified infections requiring IV antibiotics
❑ Patient is clinically unstable

❑ Patient and physician decision
 
Administer IV empirical antipseudomonal antibiotic monotherapy (URGENT):

Cefepime
or
Piperacillin-tazobactam
or
Meropenem
or

Imipenem cilastatin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inpatient monitoring:

Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with
❑ Daily review of systems
❑ Daily physical examination
❑ Cultures of specimens from suspicious sites

❑ Focused imaging studies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider discharge with outpatient oral broad-spectrum antibiotics:

❑ Ability to tolerate oral medications
❑ Availabilty of telephone, transportation to hospital, caregiver
❑ Fulminant infections are excluded
❑ Patient is clinically stable

❑ Patient and physician decision
 
 
Add vancomycin to the initial empirical antibiotic monotherapy for:

❑ Suspected Catheter related infection
❑ Suspected skin and soft tissue infection
❑ Suspected pneumonia
❑ Hemodynamic instability
❑ Positive gram-positive bacterial blood culture (that is available before the final identification and susceptibility test)
❑ Colonization with MRSA, VRE, or penicillin-resistant streptococcus pneumoniae
❑ Severe mucositis (following fluoroquinolone prophylaxis and use of ceftazidime as empirical therapy)


Consider modifying the initial empirical antibiotic monotherapy for:
❑ Suspected antimicrobial resistance:

❑ Patient is unstable
❑ Patient's positive blood culture is suspicious for a resistant bacteria
❑ Patient has/had treatment in a hospital with high rates of endemicity
❑ Patient had previous history of any infection or colonization with an organism

or
❑ Proven antimicrobial resistance where the blood cultures are positive for resistant bacteria

ForAdd
MRSAVancomycin
or
Linezolid
or
Daptomycin
VRELinezolid
or
Daptomycin
ESBLsCarbapenem
KPCsPolymyxin colistin
or
Tigecycline
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Outpatient monitoring:

❑ Monitor for recovery, adverse drug effects, secondary infections and development of drug-resistance with

❑ Daily review of systems
❑ Daily physical examination
❑ Cultures of specimens from suspicious sites
❑ Focused imaging studies

❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care
❑ Consider re-admission for IV broad-spectrum antibiotics in case of

❑ Persisting fever
❑ Recurrent fever
❑ New signs of infection
❑ Decreasing neutrophil counts
 
 
 
 
 
 
 
 
 
 
 

Days 2 to 4: Management of Low Risk Patients With Febrile Neutropenia After Day 1 Management

Shown below is an algorithm depicting the days 2 to 4 management of low risk patients with febrile neutropenia based on the clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America (IDSA).[1]

 
 
 
 
 
 
 
 
Low risk patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unexplained fever after day 1
 
 
 
Clinically or microbiologically documented infection during day 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Persistent or recurrent fever
and/or
❑ Clinically unstable
 
❑ Responding to initial empirical therapy
and/or
❑ Cultures negative
 
Modify antibiotics according to culture results and/or infection site:
Culture results and/or infection siteModified regimen
❑ Gram-negative bacteremia❑ Administer a combination of
Beta-lactam
or
Carbapenem

plus

Aminoglycosides
or
Fluoroquinolones

and

❑ Switch to a monotherapy with a beta-lactam agent once the susceptibilities are known
❑ Gram-positive bacteremia or skin and soft-tissue infections ❑ Administer
Vancomycin
or
Linezolid
or
Daptomycin

and

❑ Adjust regimen based on susceptibility of pathogen
Pneumonia❑ Administer a combination of
Beta-lactam
or
Carbapenem

plus

Aminoglycosides
or
❑ Antipseudomonal fluoroquinolones

and
❑ If MRSA suspected add

Vancomycin
or
Linezolid

and

❑ Adjust regimen based on susceptibility of pathogens and clinical progress
HSV or candida esophagitis❑ Administer acyclovir and/or fluconazole
Neutropenic enterocolitis❑ Adminsiter
❑ Monotherapy: Piperacillin-tazobactam or carbapenem
or
❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Inpatient management:
❑ Hospitalize the patients who are on outpatient broad-spectrum antibiotics
❑ Continue the patients who are on inpatient IV broad-spectrum antibiotics with inpatient management


Order:
❑ A new set of blood cultures
❑ Stool sample for clostridium difficile antigen and toxin assay (if diarrhea is present)
❑ Abdominal CT (if abdominal pain and diarrhea is present)
❑ Other symptom related diagnostic tests


Consider noninfectious causess:
❑ Drug related fever
❑ Thrombophlebitis
❑ Underlying cancer

❑ Resorption of blood from a large hematoma
 
Continue the initial oral or IV broad-spectrum antibiotics until:

❑ ANC is >500 cells/mm3 and rising


Outpatient management:
❑ Consider discharging patients with oral broad-spectrum antibiotics

❑ Ability to tolerate oral medications
❑ Availabilty of telephone, transportation to hospital, caregiver
❑ Fulminant infections are excluded
❑ Patient is clinically stable
❑ Patient and physician decision

❑ Monitor the patients for recovery, adverse drug effects, secondary infections and development of drug-resistance with

❑ Daily review of systems
❑ Daily physical examination
❑ Cultures of specimens from suspicious sites
❑ Focused imaging studies

❑ Ensure 24 hours a day and 7 days a week access to the appropriate medical care
❑ Consider re-admission of patients in case of

❑ Persisting fever
❑ Recurrent fever
❑ New signs of infection
❑ Decreasing neutrophil counts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Modify antibiotics according to culture results and/or infection site:
Culture results and/or infection siteModified regimen
❑ Drug-resistant gram-negative bacteria

❑ Drug-resistant gram-positive bacteria

❑ Drug-resistant anaerobes
❑ Change from initial cephalosporin to
Imipenem
or
Meropenem

❑ If initially on vancomycin add

Aminoglycoside
or
Ciprofloxacin
or
Aztreonam
❑ Suspected systemic inflammatory response syndrome❑ Add fluconazole
Clostridium difficile❑ Add
❑ Oral vancomycin
or
❑ Oral metronidazole
Neutropenic enterocolitis❑ Adminsiter
❑ Monotherapy: Piperacillin-tazobactam or carbapenem
or
❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole
 
 
 
 
Responding
 
Not responding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Continue antibiotics

❑ For 7-14 days as appropriate for documented infection
or
❑ Until ANC >500 cells/mm3 and rising

and
❑ Consider resuming oral fluoroquinolone prophylaxis until ANC >500 cells/mm3 and rising in patients

❑ Who remain neutropenic after completion of appropriate treatment
❑ Who's signs and symptoms of a documented infection has resolved
 
 
 
 
 
 
❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection
❑ Consider culturing, biopsy, or draining sites of worsening infection
❑ Consider reviewing antibiotic coverage for adequacy of dosing and spectrum
❑ Consider adding empirical antifungal therapy
❑ Broaden antimicrobial coverage for hemodynamic instability
 
 
 

Days 2 to 4: Management of High Risk Patients With Febrile Neutropenia After Day 1 Management

Shown below is an algorithm depicting the days 2 to 4 management of high risk patients with febrile neutropenia based on the clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America (IDSA).[1]

 
 
 
 
 
 
High risk patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unexplained fever after day 1
 
 
 
Clinically or microbiologically documented infection during day 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Persistent or recurrent fever
and/or
❑ Clinically stable
 
❑ Responding to initial empirical therapy
and/or
❑ Cultures negative
 
Modify antibiotics according to culture results and/or infection site:
Culture results and/or infection siteModified regimen
❑ Gram-negative bacteremia❑ Administer a combination of
Beta-lactam
or
Carbapenem

plus

Aminoglycosides
or
Fluoroquinolones

and

❑ Switch to a monotherapy with a beta-lactam agent once the susceptibilities are known
❑ Gram-positive bacteremia or skin and soft-tissue infections ❑ Administer
Vancomycin
or
Linezolid
or
Daptomycin

and

❑ Adjust regimen based on susceptibility of pathogen
Pneumonia❑ Administer a combination of
Beta-lactam
or
Carbapenem

plus

Aminoglycosides
or
❑ Antipseudomonal fluoroquinolones

and
❑ If MRSA suspected add

Vancomycin
or
Linezolid

and

❑ Adjust regimen based on susceptibility of pathogens and clinical progress
HSV or candida esophagitis❑ Administer acyclovir and/or fluconazole
Neutropenic enterocolitis❑ Adminsiter
❑ Monotherapy: Piperacillin-tazobactam or carbapenem
or
❑ Combination therapy: Anti-pseudomonal cephalosporin plus metronidazole
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess for infection sites
❑ Include CT of the chest and sinuses to assess for invasive fungal infection
 
Continue antibiotics until ANC >500 cells/mm3 and rising
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ No changes in empirical antibiotics
❑ Consider continuing the empirical antibiotic therapy until ANC >500 cells/mm3 and rising
❑ Consider modifying the empirical antibiotic coverage based on the clinical or microbiologic evidence of infections (including anti-fungal agents)
❑ Consider starting fluoroquinolone prophylaxis for the remaining duration of neutropenia if afebrile for 4-5 days
Levofloxacin
or
❑ Ciprofloxacin
❑ Consider switching from inpatient to outpatient oral or IV antibiotic regimens if the patients fever has subsided, combined with careful daily follow up
 
Recurrent fever during persistent neutropenia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Responding
 
Not responding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Continue antibiotics

❑ For 7-14 days as appropriate for documented infection
or
❑ Until ANC >500 cells/mm3 and rising

and
❑ Consider starting oral fluoroquinolone prophylaxis (levofloxacin or ciprofloxacin) until ANC >500 cells/mm3 and rising in patients

❑ Who remain neutropenic after completion of appropriate treatment
❑ Who's signs and symptoms of a documented infection has resolved
 
❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection
❑ Consider culturing, biopsy, or draining sites of worsening infection
❑ Consider reviewing antibiotic coverage for adequacy of dosing and spectrum
❑ Consider adding empirical antifungal (antiyeast or antimold) therapy
❑ Broaden antimicrobial coverage for hemodynamic instability
 

After Day 4: Management of High Risk Patients With Febrile Neutropenia

Shown below is an algorithm depicting after the day 4 management of high risk patients with febrile neutropenia based on the clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America (IDSA).[1]

 
 
 
 
 
 
 
 
High risk patients with prolonged (>4 days) fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Daily review of systems
❑ Daily physical examination
❑ Blood cultures (repeat on limited basis)
❑ Cultures for any suspected sites of infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unexplained fever after day 4:
❑ Clinically stable
ANC rising (myeloid recovery imminent)
 
 
 
 
 
Unexplained fever after day 4:
❑ Clinically stable
❑ ANC not rising (myeloid recovery not imminent)
❑ Consider CT scan sinuses and lungs
 
 
 
 
 
Clinically or microbiologically documented infection during days 1-4:
❑ Clinically unstable
❑ Worsening symptoms and signs of infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Observe the patient
❑ No changes in the antimicrobial regimen unless signs of new infection

❑ Clinical
or
❑ Microbiologic
or

❑ Radiological
 
 
Patients receiving antiyeast (candida) prophylaxis:

Fluconazole
or
Itraconazole
or
Voriconazole
or
Posaconazole
or
Micafungin
or
Caspofungin


For:
❑ Allogeneic hematopoietic stem cell transplantation
or

❑ Intensive remission-induction or salvage induction chemotherapy following acute leukemia
 
 
 
Patients receiving antimold (aspergillosis, zygomycosis, fusariosis) prophylaxis:

Posaconazole


For:
❑ Intensive chemotherapy following acute myeloid leukemia or myelodysplastic syndrome with an age >13 years
or
❑ Prior invasive aspergillosis
or
❑ Anticipated prolonged neutropenic periods (>2 weeks)
or

❑ Prolonged period of neutropenia prior to hematopoietic stem cell transplantation
 
 
❑ Consider re-examination and re-imaging studies (CT, MRI) for new or worsening sites of infection
❑ Consider culturing, biopsy, or draining sites of worsening infection
❑ Consider reviewing antibiotic coverage for adequacy of dosing and spectrum
❑ Consider adding empirical antifungal therapy
❑ Broaden antimicrobial coverage for hemodynamic instability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preemptive antifungal management:
Order:

❑ CT chest and sinuses

❑ Macronodules with or without halo sign
❑ Cavitary lesions

❑ Serial serum b-(1-3)-D glucan test for

Candida species
Aspergillus species
Pneumocystis species
Fusarium species

❑ Serial serum galactomannan test for

Aspergillus species

Administer appropriate antifungal therapy if:
❑ Clinically unstable
and/or
❑ Clinical or chest and sinus CT signs of fungal infection
and/or
❑ Positive serologic assay results for evidence of invasive fungal infection
and/or
❑ Recovery of fungi (eg. candida or aspergillus species) from any body site


Withhold existing antifungal therapy if:
❑ Clinically stable
and/or
❑ No clinical or chest and sinus CT signs of fungal infection
and/or
❑ Negative serologic assay results for evidence of invasive fungal infection
and/or

❑ No fungi (eg. candida or aspergillus species) recovered from any body site
 
Add antimold therapy to the empirical antiyeast therapy:
Echinocandin
or
Voriconazole
or
Amphotericin B preparation
 
Consider switching to a different class of antimold agent
 
 

Do's

  • Modify the antibiotic regimens depending on the clinical picture and the epidemiology of infections in the area and the hospital where the patient is being treated at.

Don'ts

  • Don't measure the temperature of the patient in the axillary area because it is not as specific as if it was taken orally.
  • Don't measure the temperature of the patient rectally to avoid contaminating the skin and soft tissues of the rectal area.

References

  1. 1.0 1.1 1.2 1.3 1.4 Freifeld, AG.; Bow, EJ.; Sepkowitz, KA.; Boeckh, MJ.; Ito, JI.; Mullen, CA.; Raad, II.; Rolston, KV.; Young, JA. (2011). "Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america". Clin Infect Dis. 52 (4): e56–93. doi:10.1093/cid/cir073. PMID 21258094. Unknown parameter |month= ignored (help)


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