FEBRILE NEUTROPENIA
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Transcript FEBRILE NEUTROPENIA
Saima Abbas M.D
Infectious Diseases
Fellow-PGY5
Why is this an Oncologic
emergency ??
Infection + ABX + Immune
system = cure
Normal Gross
Anatomy
Skin Integrity
Intact mucous
membranes
Intact ciliary
function
Absence of
Foreign Bodies
Innate Immunity
( PMN,
Macrophages, NK
cells, Mast cells and
basophils)
Complement
Adaptive immunity
T cells CD 4 and CD 8
B cells
Case 1
July 10th 2009 - NF 1
You are paged at 5:00am by the nurse
taking care of Mr. Thomas on 4 AB
He spiked a fever of 38 C (100.4F) one
hour ago.
-There is no order for Tylenol.
~ You check your Hem Oncology List .
Per sign out:
The patient was recently diagnosed with
AML is S/P chemotherapy and is stable.
You can
Order Tylenol and take the next page.
OR…..
OR
Am I missing febrile
Neutropenia???
If you are alert, you think…
What are the facts you need to
know?
Does 38 C define febrile neutropenia?
What’s his Absolute Neutrophil Count?
Any transfusion in the last 6 hours?
Definition of Fever in FN
A single oral temp 38.3 C
(101 F)
or
A temperature of 38 C
(100.4F) on two occasions
separated by 1 hour
You request her to repeat the
temperature and she reports 38. 2 C
(100.8 F)
Don’t be tricked
If temperature 37 38 C , repeat
temperature in 1 hour to see if the
above criteria for treatment are met
Clinical signs of septicemia
Good history of fever detected by
patient before admission and afebrile
when you evaluate the patient.
Definition of Neutropenia
ANC 500/mm3 or
1000/mm3 and predicted
decline to 500/mm
~ Clin Inf Dis, 2002;34:730-51
ANC : Mr. Thomas
WBC 0.7
Segs = 38%
Bands = 2%
Absolute Neutrophil Count
(Total # of WBC) x (% of Neutrophils) =
ANC
Take the percent of neutrophils (may
also be polys or segs) + percent bands
Convert percent to a decimal by
dividing by 100 (Example 40% = 40/100
= 0.40) (*move the decimal 2 points to
the left)
Multiply this number by the total White
Blood Cells (WBC)
Calculation
Neutropenia
Normal ANC 1500 to 8000 cells/mm³
Neutropenia: ANC < 1500 cells / mm3
Mild Neutropenia: 1000-1500 cells / mm3
Moderate Neutropenia: 500-999 cells /
mm3
Severe Neutropenia: < 500 cells / mm3
Profound Neutropenia: <100 cells/ mm³
When Does Neutropenia
Occur?
Most chemotherapy agents/protocols
cause neutropenia nadir at 10-14 days
But can see anytime from a few days
after chemotherapy to up to 4-6
weeks later depending on the agents
used
Risk of Infection as Absolute Neutrophil Count Declines
Epidemiology
Up
to 60% febrile neutropenia
episodes = infection
(microbiological or clinical)
~20%
patients with ANC <100
cells/mm³ with febrile neutropenia
episodes have bacteremias.
Epidemiology
--NEJM, 1971;284:1061
Retrospective data have shown that
~ 50 % of Pseudomonas Aeruginosa
Bacteremia result in death within 72 hours
when ANC is < 1000
Early trials aimed at Pseudomonas showed that
Carbapenicillin /Gentamicin decreased Mortality
by 33 %
~Journal of Infectious diseases, 1978;147:14
Epidemiology
Viscoli et al, Clin Inf Dis;40:S240-5
Changing etiology of bacteremia
IATG-EORTC 1973-2000 trials of febrile neutropenia
Gram positive
dominant since mid
1980s
Gram negative resurgence
1) More intensive
chemoTx
•Mucositis
2) In-dwelling catheters
• Cutaneous-IV portal
3) Selective antiBx
pressure
•Fluoroquinolones
• Co-trimoxazole
4) Antacids
•Promote orooesophageal
colonisation with
GPC
Duration of Neutropenia
< 7 days LOW risk
7 to 14 days INTERMEDIATE RISK
> 14 days HIGH RISK
Duration Of Neutropenia
1988,Rubin and colleagues
< 7 days of neutropenia
~ response rates to initial antimicrobial
therapy was 95%, compared to only
32% in patients with more than 14
days of neutropenia ( <.001)
~ patients with intermediate durations of
neutropenia between 7 and
14 days had response rates of 79%
Common Microbes
Gram-positive cocci
and bacilli
Staph. aureus
Staphylococcus
epidermidis
Enterococcus
faecalis/faecium
Corynebacterium
species
Gram-negative
bacilli and cocci
Escherichia coli
Klebsiella species
Pseudomonas
aeruginosa
FUNGI
Candida- Non
albicans emerging
Aspergillus >> in
HSCT
Initial evaluation
Ensure Hemodynamic Stability and No NEW
ORGAN DYSFUNCTION
History
Underlying disease, remission and transplant
status- spleen +/ Chemotherapy
Drug history (steroids, any previous antibiotics)
Allergies
Focused Review of systems
Transfusions
Can cause fevers
Lines or in-dwelling hardware
THINK Strep.
Pneumoniae
Neisseria meningitidis
Hemophilus Influenzae
Splenectomy
Exam (be prepared to find no
signs of inflammation)
HEENT Look in the mouth any oral
sores – periodontium, the pharynx
Lungs
Abdomen for tenderness- RLQ (signs of
Typhilitis)
Perineum including the anus -No rectal
exam !
Skin Exam- Ask the patient for
any area of tenderness?
Skin –
Bone marrow aspirations sites,
vascular catheter access sites
and tissue around the nails
Rashes (Drug eruptions/herpes zoster
reactivation / Petechial rashes all are
common in these patients)
Febrile neutropenia
Investigation
Complete Blood Count (with Differential)
-White cells, haemoglobin, platelets
Biochemistry
-Electrolytes, urea, creatinine, Liver function
Microbiology
-Blood cultures (peripheral and all central line lumens)
-Oral ulcers or sores –send swabs ( Viral Cx and fungal Cx )
-Exit site swabs
-Wound swabs
-Urine Cultures (SSx/Foley Catheter) [- pyuria ?? UA]
-Stool Cultures and CDiff Toxin/PCR
Radiology
-Chest Xray +/- CT abdomen/pelvis
Lumbar puncture
Examination of CSF specimens is not
recommended as a routine procedure
but should be considered if a CNS
infection is suspected and
thrombocytopenia is absent or
manageable.
Skin lesions
Aspiration or biopsy of skin lesions
suspected of being infected should be
performed for cytologic testing, Gram
staining, and culture
IMAGING in FN
CXR if Symptomatic or if out pt Rx
considered
High resolution CT Chest Indicated ONLY
if persistent fevers with pulmonary
symptoms after initiation of empiric Abx
CTA if suspect PE
CT abdomen for Necrotizing Enterocolitis
or Typhilitis
CT brain R/o ICH / MRI of the spine or
brain - more for evaluation of metastatic
disease than FN
Stratify risk of complications
1. Neutropenia
with severity of neutropenia (< 50/mm3)
with duration of neutropenia (>7 days)
2.Bacteremia
Gram negative > gram positive
3.Underlying malignancy and status
Acute Leukemia
Relapsed disease
Solid malignancies: Local effects eg obstruction,
invasion
4.Co-morbidities, age >60
HIGH risk Patients
• Prolonged Neutropenia (>14 days)
• Haematological malignancy/ Allogenic HSCT
• Myelosuppresive chemotherapy
• Concurrent chemotherapy and radiotherapy
• Age >60
• Co-morbidities eg. Diabetes, poor nutritional status.
• Bone marrow involvement of cancer
• Delayed surgical healing or open wounds
• Significant mucositis
• Unstable (eg hypotensive, oliguric)
• On steroid dose >20mg prednisone daily
• Recent hospitalization for infection
a Concomitant condition of significance (e.g.,shock, hypoxia, pneumonia,
or other deep organ infection, vomiting, or diarrhea).
Risk model
Model 2
(Klatersky et al MASCC 2000 J Clin Onc)
•No or Mild symptoms
•Moderate symptoms
•No Hypotension
•No COPD
•Solid tumour /
Haem malignancy
(no fungal infection)
•Outpatient
•No dehydration
•Age <60 yrs
LOW RISK=score>20
5
3
5
4
4
3
3
2
ORAL vs IV
For patients who are low risk for
developing infection-related
complications during the course of
neutropenia,
~ Oral ciprofloxacin plus
amoxicillin/clavulanate
~ Oral ciprofloxacin plus clindamycin
for PCN allergy
If inpatient and high risk
EMPIRIC ANTIMICROBIAL
THERAPY after Blood
Cultures.
Must be initiated within 1
hour
THREE approaches for IV
EMPIRIC therapy
IV MONO THERAPY
IV DUAL THERAPY
COMBINATION THERAPY
Mono or dual therapy + VANCOMYCIN
Monotherapy IV
1.
Extended spectrum Antipseudomonal
Cephalosporins
•
•
2.
Carbapenem
•
•
3.
Cefepime
Ceftazidime
Imipenem –Cilastatin
Meropenem
Anti –Pseudomonal PCN
•
•
Piperacillin- Tazobactam
Ticarcillin- Clavulanic acid
DUAL therapy
1.
an aminoglycoside
plus
an antipseudomonal penicillin
(with or without a beta-lactamase
inhibitor)
or
an extended-spectrum
antipseudomonal cephalosporin,
Dual therapy
(2) ciprofloxacin plus an
antipseudomonal penicillin.
Indications
Unstable patient
H/O P. aeruginosa colonization or
Invasive disease
5 Indications for Vancomycin
1. clinically suspected serious catheter-related
infections
2. known colonization with penicillin- and
cephalosporin-resistant pneumococci or MRSA,
3. positive results of blood culture for gram-positive
4.
hypotension or other evidence of cardiovascular
impairment
5. H/O ciprofloxacin or trimethoprim-sulfamethoxazole
vancomycin resistant
enterococcus
Linezolid
Daptomycin (avoid for pneumonia)
Quinopristin- Dalfopristin
PCN allergy
NON – ANAPHYLACTIC
If not allergic to cephalosporins
~ Cefepime
ANAPHYLACTIC and allergic to
cephalosporins~Aztreonam +/- Aminoglycoside or a FQ
+/- Vancomycin if indicated
MAINTAIN BROAD
SPECTRUM ACTIVITY
FOR A MINIMUM OF 7
DAYS OR UNTIL ANC
>500
Antibiotic stopping guide
IDSA, Clin Infect Disease, 2002
Minimum 1 week of therapy if
Afebrile by day 3
Neutrophils >500/mm3 (2 consecutive days)
Cultures negative
Low risk patient, uncomplicated course
> 1 week of therapy based if
Temps slow to settle (>3 days)
Continue for 4-5 days after neutrophil recovery (>500/mm3 )
Minimum 2 weeks
Bacteraemia, deep tissue infection
After 2 weeks if remains neutropenic (< 500/mm3), BUT afebrile, no
disease focus, mucous membranes, skin intact, no catheter site
infection, no invasive procedures or ablative therapy
planned…cease antibiotics and observe
When temperatures do not go
away…
Non-bacterial infection (eg fungal, viral)
Bacterial resistance to first line therapy (MRSA,
VRE)
Slow response to drug in use
Superinfection
Inadequate dose
Drug fever
Cell wall deficient bacteria (eg Mycoplasma,
Chlamydia)
Infection at an avascular site (abscess or catheter)
Disease-related fever
Antifungals
Easy to Initiate/ Difficult to stop
Aggressive search for Fungal Infections
Pulmonary Aspergillosis/Sinusitis /
Hepatic Candidiasis
CT Chest and Abdomen
CT Sinuses
Cultures of suspicious skin lesions
ANTI FUNGALS
AMPHO B IV drug of choice for high
risk patients
Alternative options
FLUCONAZOLE
ITRACONAZOLE
ECHINOCANDINS
Voriconazole is NOT FDA approved for
empiric therapy for persistent fevers in
FN
Fluconazole ~ candida
Fluconazole
acceptable if NO
Moulds and Resistant
Candida
( C. Krusei and C.
glabrata )
Uncommon.
Low risk patients
DO NOT Use
Fluconazole if
Evidence of
Sinusitis or
Radiographic
evidence of
Evidence of
Pulmonary disease
If patient has
received
Fluconazole
prophylaxis before.
Itraconazole
In a recent controlled study of 384
neutropenic patients with cancer,
itraconazole and amphotericin B were
equivalent in efficacy as empirical
antifungal therapy.
FOR BOARDS use AmphoB OR
Itraconazole- hopefully should not ask
you to choose between Itraconazole and
Ampho B
Antibiotic Prophylaxis for
Afebrile Neutropenic Patients
Use of antibiotic prophylaxis is not routine
because of emerging antibiotic resistance **,
except for
Trimethoprim-sulfamethoxazole to prevent
Pneumocystis carinii pneumonitis.
Antifungal prophylaxis with fluconazole
Antiviral prophylaxis with acyclovir or ganciclovir
are warranted for patients undergoing allogenic
hematopoietic stem cell transplantation.
** CID 40:1087&1094,2005
NEJM 353:977,988&1052,2005
Use of Antiviral Drugs
Antiviral drugs are not recommended for
routine use unless clinical or laboratory
evidence of viral infection is evident.
Granulocyte Transfusions
Granulocyte transfusions are not
recommended for routine use.
Use
of Colony-Stimulating Factors
Use of colony-stimulating factors is
not routine but should be
considered in certain cases with
predicted worsening of course.
Role of G-CSF
Studies of G-CSF used in febrile
neutropenia show:
Length of neutropenia but generally not
hospitalization
No mortality advantage
Generally not recommended
Exception may be those in high risk
group esp. if unstable
Updates not for BOARDS but
for clinical practice
JAC 57:176,2006
A meta analysis of 33 RCTs until Feb
2005 on Antipseudomonal B lactams as
MONOtherapies showed that
~CEFEPIME increases 30 day all cause
mortality
~ Carbapenems were associated with
increased Pseudomembranous colitis.
Special Situations
Neutropenic Enterocolitis or
Typhilitis
Inflammatory process involving colon
and/or small bowel
ischemia, necrosis, bacteremia
( translocation from gut) hemorrhage,
and perforation.
Fever and abdominal pain ( typically
RLQ).
Bowel wall thickening on
ultrasonography or CT imaging.
Treatment
( 50-70% mortality)
Initial conservative management
○ bowel rest,
○ intravenous fluids,
○ TPN,
○ broad-spectrum antibiotics
○ and normalization of neutrophil counts.
Surgical intervention
○ obstruction, perforation, persistent
gastrointestinal bleeding despite correction of
thrombocytopenia and coagulopathy, and
clinical deterioration.
Consider Pseudomonal and Clostridial coverage
in Empiric therapy
Clostridium
Septicum
Clostridium Sordelli
Cover with PEN G ,AMP,
Clindamycin*
Broad Spectrum Abx ( carbapenem )
include Metronidazole if unsure of
Cdiff
* resistance of Clostridia to clindamycin
reported.
H/O leukemia and prolonged
antibiotic therapy
Angioinvasive Aspergillosis
Confirm with Biopsy
Aggressive Antifungal Therapy
Voriconazole (Drug of Choice)
Caspofungin FDA approved for Ampho and
Voriconazole refractory Aspergillus.
Case 1- Mr. Thomas
June 20th 2009 – diagnosed AML
June 21st 2009 – R subclavian
Hickman placed and Chemotherapy
initiated
Remission Induction S/P 7+ 3 regimen
Cytarabine (Ara C) and Daunorubicin
June 28th 2009 - last dose of
chemotherapy.
July 10th 2009 - Febrile Neutropenia
ANC 280 ANC < 500 last 2 days
Experiences chills with CVC flushing
and erythema and tenderness is noted
over the hickman exit site.
Allergies NKDA
Labs Pancytopenic
LFTS ok Creatinine 1.0
What is the best next step?
1- Cefepime or Zosyn IV stat
2- Vancomycin IV stat
3- CXR
4- Blood cultures-central and peripheral
5- Fluconazole IV stat
Cefepime and Vancomycin are
initiated
Blood cultures are +
for MRSE 2/2.
Pt becomes afebrile
day 4 of ABX.
Surveillance Blood
cultures are
Negative. Patient is
stable.
ANC = 300 by DAY
4
A
B
C
D
What will you do
next?
Stop Cefepime
Add G- CSF
Continue Cepepime
until ANC > 500 or
a minimum of 7
days.
Continue
Vancomycin for a
total of 7 days.
Remember for boards
Do not order CT scan in a neutropenic
patient with a normal CXR.
In clinical practice if patient remains
febrile for 3 to 5 days then the next step
is HRCT. ( 50 % of patients with +
imaging have a normal CXR)
Conclusions
Febrile Neutropenia is a serious
complication of chemotherapy
Be vigilant for febrile neutropenia in
chemotherapy patients
Be vigilant for infection even when no
fever
Initiate EMPIRIC antibiotics immediately.
Several treatment options depending on
risk stratification.