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Febrile Neutropenia 2
Febrile Neutropenia 2
SIRIPORN PHONGJITSIRI
Febrile Neutropenia
Febrile Neutropenia
Febrile Neutropenia
Bacterial infection
Neutropenia :single most important risk
factor for infection in cancer pts.
Risk of infection increases 10-fold with
declining neutrophil counts < 500/mm3
Febrile Neutropenia
Febrile Neutropenia
Level of Fever & Neutropenia
Fever : single oral temp. >
temp. >38.0 0C for >
38.3 0C or a
1 hr
< 500 /
Febrile Neutropenia
Evaluation
History
Physical examination : minimal signs
Risk assessment
Investigations
URTI
Dental sepsis
Mouth ulcers
Skin sores
Exit site of central venous catheters
Anal fissures
GI
Preantibiotic Investigations
Blood C/S : central line & peripheral
Chest X-Ray
Urine C/S
Stool C/S
Biopsy cultures
Viral studies
Febrile Neutropenia
Febrile Neutropenia
Bacterial causes (EORTC)
Gram-positive bacteria (60-70%)
Gram-negative bacilli (30-40%)
Gram-positive Bacteria
Staphylococcus spp :
MSSA,MRSA,
Streptococcus spp : viridans
Enterococcus faecalis/faecium
Corynebacterium spp
Bacillus spp
Stomatococcus mucilaginosus
Gram-negative Bacteria
Escherichia coli
Klebsiella spp : ESBL
Pseudomonas aeruginosa
Enterobacter spp
Acinetobacter spp
Citrobacter spp
Stenotrophomonas maltophilia
Anerobic Bacteria
Bacteroides spp
Clostridium spp
Fusobacterium spp
Propionibacterium spp
Peptococcus spp
Veillonella spp
Peptostreptococcus spp
Febrile Neutropenia
Low Risk
ANC > 100 /mm3
Normal CXR
Duration of neutropenia < 7 d
Resolution of neutropenia <10 d
No appearance of illness
No comorbidity complications
Malignancy in remission
Monotherapy
Choices
Ceph 3 : ceftazidime
Ceph 4 : cefepime
Carbapenem : imipenem , meropenem
IDSA guidelines-2002
Combination Therapy
Advantages
Combination Therapy
Disadvantages
Drug toxicities
Drug interactions
Potential cost increase
Administration time
Combination Therapy
Choices
Aminoglycoside + Anti-pseudomonal
carboxypenicillin
Aminoglycoside + Anti-pseudomonal
cephalosporin
Aminoglycoside + Carbapenem
Vancomycin as Empiric Rx
When to use ?
Known colonization with MRSA or PRSP
Clinically suspected serious catheterrelated infections (eg bacteremia)
Hypotension or cardiovascular impairment
Initial positive results of blood culture for G
+ bacteria
Febrile Neutropenia
Persistence of fever
Clinical deterioration
Culture results
Drug intolerance/side effects
Persistent Fever
Causes
Nonbacterial infection
Resistant bacteria
Slow response to antibiotics
Fungal sepsis
Inadequate serum & tissue levels
Drug fever
Febrile Neutropenia
3 days of Rx
Clinically well
Febrile Neutropenia
Conclusions
Significant morbidity & mortality
Choice of initial empiric therapy dependent
on epidemiologic & clinical factors
Monotherapy as efficacious as
combination Rx
Modifications upon reassessment
Duration dependent on ANC