Transcript Managing Fever in the Presence of Neutropenia or Central Lines

Managing Fever in the Presence
of Neutropenia or Central Lines
Chadi ELtaha, MD
PGY II - PEDS
Fever and Neutropenia
Muy Importante!
Fever in a patient with cancer or
on chemotherapy is a medical
emergency
Mortality is 1-5%
Definitions
Fever:
 Single oral T>101oF (38.3oC)
OR
 T=100.4oF (38oC) on two separate readings
one hour apart
Oral is best; take axillary if oral temp impossible
No conversion needed
AVOID rectal temperature in any oncology
patient at any time
Definitions
Neutropenia:
ANC < 1500
Mild 1500-1000
Moderate 1000-500
Severe <500
Profound <200
Risk of infection in cancer patients is high if
ANC<1000
Definitions
Calculating the ANC:
Total WBC count x (% neutrophils + % bands)
WBC= 3.1, neutrophils 30%, bands 4%
What is the ANC?
WBC= 2.4, neutrophils 0%, bands 0%
What is the ANC?
Risk
Infection risk increases with:
Any break in the skin barrier
Any foreign body: central lines, indwelling ports,
Foley catheters, NG tubes, shunts, rods,
prostheses
Prolonged neutropenia
History
Duration of fever? Accompanied by chills?
Fatigue?
Rhinorrhea?
Cough?
Abdominal pain or GI symptoms?
Dysuria?
Central line?
Physical Exam
Thorough exam, including:
Oral exam for ulcerations
Perirectal exam for lesions
Nares for lesions, especially if NGT feeds
Skin exam
Central line for phlebitis, cellulitis
Admission Investigations
 CBC with diff, CRP, blood cultures from
periphery x 1, blood cultures from all lumens of
all central lines, CP14 (most chemo patients will
have abnormalities)
 urinalysis and culture (must be clean catch-catheterization contraindicated in neutropenia)
 viral respiratory culture and rapid flu and RSV if
indicated
 If diarrhea, C. diff toxin, fecal WBCs, stool
culture
Admission Investigations
Radiologic Studies
CXR (debatable if no pulmonary symptoms)
Sinus CT if symptoms or if all other workup
negative
Abdominal CT if significant abdominal pain
(worry about neutropenic colitis, aka acute
typhilitis)
Beware…
CXR may not have an infiltrate apparent
during neutropenia—may change after
counts recover
Urinalysis may not have WBCs or
leukocyte esterase during neutropenia—
send a culture
Daily Labs
CBC with differential to follow ANC
CRP if previously elevated
CP14 if indicated (if needs supplements or
on TPN)
Blood cultures while febrile (can be from
central line, don’t have to have peripheral)
Medications
 Ceftazadime or Cefepime 50 mg/kg/dose IV Q8
hours, max 2g/dose
 Add Vancomycin 15 mg/kg/dose IV Q6 hours if
signs of line infection.
 Add Gentamicin 5 mg/kg/day IV Q24 hours if
hypotension and chills
 Add Amphotericin B if persistent neutropenia
and fever >4-5 days despite antibiotics
 * Both Cefepime and Ceftazadime can cause
neutropenia, even in healthy people!
To culture or not?
Recollect blood cultures in these cases:
Before adding or changing an antibiotic
Persistent fever (get one culture per day while
febrile, best to get when actually febrile, don’t
always have to have a peripheral)
During times of clinical deterioration
If you are called with a positive culture
You don’t need 8 million cultures in a day!
What if something grows?
Order another culture
Look at your antibiotics and see if you
should have coverage
Follow-up on the sensitivities; should be
available the next day
Tailor antibiotics if possible
If a true infection, ECHO
Contaminant or Not?
Unlikely to be true pathogens:
Corynebacterium, non-anthracis Bacillus,
Propionibacterium acnes
Uncertain significance:
Coagulase negative staph
If your patient was unstable, has a CVL, or this
grows in multiple cultures, maybe so!
Probably so:
S. aureus, S. pneumo, Enterobacter, P.
aeruginosa, C. albicans, Aspergillus
Consider…
If multiple positive blood cultures,
likelihood of true bacteremia increases
If cultures are repeatedly positive for coag
neg staph or if peripheral and CVL
cultures are positive at the same time,
likelihood of true bacteremia increases
How long do you treat?
Depends on the organism and if they have
a central line that you want to keep
Depends on initial clinical appearance
Usually minimum of 14 days for CVL,
sometimes longer; ask your friendly ID
expert!
Start counting your days of antibiotics from
the date the first negative cx was drawn,
not from first day of antibiotics
What if nothing grows?
This will happen more often than not.
You can stop antibiotics when
Afebrile for 48 hours
Counts recovered (ANC >500)
All cultures negative for 48-72 hours, and any
positive cultures treated fully
Clinically stable
Your attending says so!
Fever and Central Lines in the
Absence of Neutropenia
Types of Central Lines
Hickman catheter:
Seen more in infants and toddlers
Placed surgically in the chest wall; needs
surginet
Benefits: always accessed, no needle stick
to draw blood or infuse
Drawbacks: always accessed, increasing
risk of infection, hanging on chest, gets
pulled by frisky kids
0100…
RN calls you because Ricky, a 3 yo with
ALL, was found running in the hall with his
IV pole behind him attached to his
Hickman catheter. She thinks he might
have pulled out the line some.
What do you want to do?
Other than installing a lock…
 Inspect the chest for any changes
 Be sure that he has surginet over his trunk to
secure line
 See if there is still blood return
 Get a CXR and compare it to previous
placement
 If displaced, notify surgery team and discontinue
use until repaired
 Don’t keep kids hooked up if not necessary
Types of Central Lines
Port A Cath:
Seen more in older children and
adolescents
Surgically placed in the chest wall
Benefits: cannot be pulled on because it’s
subcutaneous, theoretically less infection
Drawbacks: requires needle stick to
access or draw labs, can flip and make
access difficult
2200…
You are called because 10 yo Heaven’s
port is not drawing back blood or flushing.
She says that it hurts her.
What do you want to do?
Try…
Deaccessing the port (need to flush with
heparin before deaccessing in general)
Applying EMLA cream for comfort with
needle sticks
Reaccessing the port
If you can’t get blood return, you can’t use
it unless you have a radiology dye study to
verify placement (considered bad form to
infuse chemo or most anything subcutaneously!)
Types of Central Lines
PICC Lines (Peripherally Inserted Central
Catheter)
 Placed by specially trained team of RNs
 Benefits: OR not required for placement, allows
for IVF, TPN, and prolonged antibiotics, allows
for frequent blood draws
 Drawbacks: Infection, bleeding, DVT, air
embolism, breakage, requires weekly CXR for
placement, not usually used for chemo
By the way..
PICC handout and doctor consent form in
PICU
Consent for deep sedation
Social service consult for OPAT
(outpatient parental antimicrobial therapy)
1400…
You need a CBC on a patient with a PICC
line. Can the nurse draw it off the PICC
line or do they have to stick the patient?
Look at the original orders for the PICC
line (in the order section). They tell you if
you can draw off it or not. If you can’t find
them, ask the PICC team or use these
general guidelines…
PICC Guidelines
 Can draw labs off 3 Fr and bigger
 Can transfuse blood through 3 Fr and bigger
(risk of clotting off)
 No contrast administered unless by specially
trained RN (makes radiology techs nervous)
 1.9 Fr get heparin flushes Q4 hours and after
use (unless really tenuous, then may get
continuous heparin)
 3 Fr and bigger get NS flushes only
 Dressing changes Q week and PRN nasty
Muy importante!
Fever in a child with a central line is
bacteremia until proven otherwise
History
Why do they have a central line? Are they
already on antibiotics at home? Which
ones, what doses?
Other sources of fever?
Line care, any problems with lines, any
rash, cellulitis, pain associated with line?
Fever, chills, nausea, fatigue?
Physical Examination
Look at the line and look proximal to the
line for any streaking, phlebitis
Look for any other sources
Listen for a murmur!
Labs
CBC with diff, CRP, blood culture from
periphery and from all lumens of the
central line
Any applicable drug levels
CP14 depending on the drugs that they
are on
Other investigations for fever as indicated
Other studies
CXR for placement if needed
ECHO if murmur or a true positive blood
culture to rule out endocarditis
WARNING
NEVER try to push fluids or put CathFlo in a central line that you think
might be infected, you can release a
septic emboli!
NEVER treat any CVL infection with
PO antibiotics
ALWAYS give antibiotics through the
CVL if functioning
Medications
Ceftazadime or Cefepime 150 mg/kg/day
IV Q8 hours (covers Pseudomonas, Gram
negatives and MSSA)
Vancomycin 15 mg/kg/dose IV Q6 hours
(covers MRSA and coag neg staph)
What do you write after your Vanc order?
When should a line come out?
 For sure when there is a fungal infection
 Probably when there is a gram neg bacillus, s
aureus, or enterococci infection
 Otherwise, consult with ID regarding safety of
treating line
 If patient unstable with a Gram negative
infection, line has to come out, otherwise, may
be able to treat
 Should complete treatment before another line is
placed
 A 12-year-old boy who has acute lymphoblastic
leukemia (ALL) is undergoing reinduction
chemotherapy and has an indwelling Broviac
catheter. He has received multiple courses of
antibiotics for episodes of fever and neutropenia.
He recently completed a 6-week course of
vancomycin for persistent coagulase-negative
staphylococcal bacteremia. He is admitted to the
hospital with a temperature of 39.5°C and a
white blood cell count of 0.2x103/mcL
(0.2x109/L) (0% neutrophils). Blood culture
grows gram-positive cocci that are resistant to
vancomycin.
Of the following, the MOST likely pathogen
on the blood culture is
 A.group B Streptococcus
B.Klebsiella pneumoniae
C.Listeria monocytogenes
D.methicillin-resistant Staphylococcus
aureus
E.vancomycin-resistant Enterococcus
 A 4-year-old boy who has acute myelogenous
leukemia is admitted for the treatment of fever
and neutropenia. He has a Broviac catheter in
place. His temperature on admission is 39.3°C
and absolute neutrophil count (ANC) is less than
0.1x103/mcL (0.1x109/L). No focus of infection is
apparent on physical examination. After blood
cultures are obtained, he is begun on treatment
with piperacillin/tazobactam and gentamicin.
Five days later, the cultures remain negative,
ANC continues to be less than 0.1x103/mcL
(0.1x109/L), and his daily maximum temperature
continues to be greater than 39.3°C.
Of the following, the MOST appropriate
management at this point is to
A.add amphotericin B to the antibiotic regimen
B.administer granulocyte transfusions
C.change the antibiotic regimen to meropenem and amikacin
D.continue the present antibiotic regimen
E.stop the antibiotics and obtain another culture
THANK YOU