Febrile Neutropenia in Children with Cancer Muhammad Riza 2022¢ Febrile neutropenia is considered an oncologic emergency (in addition hyperleukocytosis) ¢ is a life-threatening condition that requires immediate attention, especially in patients with chemotherapy-related neutropenia >405002430 Definition and Criteria a single oral temperature measurement > 38.3 °C, or a temperature > 38 °C for 1 hour continuously or at two times with a minimum interval of 12 hours a total neutrophil count < 500/uL or < 1,000/uL, with decline predicted over the next 2 days Maschmeyer G et al, 2003‘a’ €& ‘ OS & Management Febrile Neutropenia in Children with Cancer Muhammad Riza, Septin Widiretnani Pendidikan Kedokteran Berkelanjutan Ee UPDATES ON PEDIATRIC INFECTIOUS DISEASES CRC UM CC AeA yal al etJOURNAL OF CLINICAL ONCOLOGY PECIAL ARTICLE Guideline for the Management of Fever and Neutropenia in Children With Cancer and Hematopoietic Stem-Cell ‘Transplantation Recipients: 2017 Update ‘Thomas Lelrnbecher, Paula Robinson, Brian Fisher, Sarah Alexander, Roland A. Ammann, Melissa Beauchemin, Fabianne Carlesse, Andreas H. Grol, Gabrielle M. Hacusler, Maria Santolaya, William J. Steinbach, Elio Castagnola, Bonnie L. Davis, I. Lee Dupuis, Aditya H. Gaur, Wim JE. Tissing. Theo Zaoutis, Robert Philips, and Lilian Sung+ Pasien dengan risiko tinggi harus diberikan antibiotik secara intravena + Sementara pasien dengan risiko rendah dan tanpa indikasi lain cukup u Risk Stratification diberikan antibiotik oral + Epidemiologi pola bakteri serta resistansi setempat sangat penting dalam menentukan jenis antibiotik empiris yang digunakan sebagai lini pertama. @aeameoCareer ner tae ee et ee ene aa ont gee ats Peerar nen rents Antibact @ameaonPe cie ttetca cole + age, malignancy type, and disease status een geet st LoCo + type and timing of chemotherapy + Height of fever, hypotension, mucositis, blood counts, and CRP‘bl 2 Vldted Pedi Risk Svatiaton Sates for Low isk Patents on per repay tc eect. “ali resto cay adequate cman fa roup ato rik of cmpeabon. 2010) act tal Satay Fact ft Aecnder etal 2000) __—Ronnlatal* 0s) Satya eta* 001) Areva et #2082) Anam eta” 2010) Freed Nee ‘Rik Baiits yrghana, ___Zporistorceoralvenaw Repeal ules, ore rarow miverant Aponte deraerap) ‘one ‘nduion ALL, progessie cater: poet forage chemotherapy within? ‘antl verouscabete, more iensve an ‘tes ome, eps wih sSyers yo episode pe-Beel eaters All mance ‘acs rarow eer Epacdozpectle Absolute moracye Hyptese,tehypeuypoxa 45 pnt er cnc ste CRP = 00m hypoianien, Absence ol cal sgn of § ports er heen fees cet < 90%, naw CXR canes, fifo; 25 pms pas = 60g Wealinecion, CRP > 80-2 Dg; 3pontseac ‘tered mantel ate, severe fer 0 URTL I pt, mg W8C = SM. fer WBC < 3004, macs, eiing or cach fer foee amg > 100g pet < 80 gt shina pan fc > BSC, hemogin infection, ordi ean = 70h forngaten aoe ‘Adefemulten Absdte manacte Absence ol any ket, ow Tot some <6, low tek Zak acta, cry ow Tbe ewer ik ats, Teta se < 9, lw rk aunt 10h, ik of serous mada ofseius infocus lates oo < Tgp fowriskof scant of advee FN lew kot camgfaton HSCT, tight campaien SCT, —‘amhemotierapy. ow cio: HSCTngh cata, SCT, gh bce high sk fiat inasve bck ik SCT, igh sk ‘atecton Demoravaed —_Unted Sues: United igdon: Dormer et Baa: Rondnalleta* South Amana: Saya top; Ammann at” Euope Medora at = tobe —Madseneta® a 005) 08 F0) (QO10; McheretaP"™ 011) ‘reins: AML sce meld ukemi, LL sea ympcblsclouemis, CP, Cation, AR chest aoa, eve andreweopeng MST, hemaopii stmcel vanslraon, UT, e@45300Assessing severity of FN Patient and disease related factors Se Oe cue orae Type of malignancy: AML; Pre-B ALL; Burkitt's lymphoma, progressive malignancy; relapse with BM involvement. Type of chemotherapy: HSCT; ALL induction; chemotherapy any chemo more intensive than ALL maintenance therapy. Timing of chemotherapy: Given within 7 days prior to onset of PN episode Other factors: presence of central venous catheter (CVC); age <5 years Vital signs: Fever > 38.5; hypotension; tachypnea; hypoxia < 94% ‘Other Signs and Symptoms: altered mental status; severe mucositis; vomiting or abdominal pain; focal infection; upper respiratory tract infect; any other specific clinical reason for inpatient aemission. Laboratory: Hemoglobin: < 70 g/Ls Platelets: < 50,000/uL; WBC: <300 /< 500; AMC: > 100/uL (low risk); Imaging: New chest X-ray changesalte Mae eae year Rk Sno Blood cultures at onset of FN Our iee re Mtg ean vc} Chest radiography only in symptomatic patients 11Tater Woe aerial aN Rk Satteston + Use monotherapy > with + Consider oral antibiotic antipseudomonal -lactam — or administration carbapenem + Used were _ fluoroquinolone + Fourth generation cephalosporin monotherapy, fluoroquinolone and (2017) amoxicillin-clavulanate and + Addition of second Gram-negative cefixime agent or glycopeptide for patients > clinically unstable, resistant infection or fresistant pathogens 12een ae eee ee ano cndcainac eterna eer Cessation of Treatment Coe iano nunic eee ea gee early peers aoc escalate regimen > resistant Gram-negative, Gram positive, and anaerobic bacteria If there is no specific microbiologic Discontinue AB 43Cee aat A encase Modification of Treatment eee ted antibiotics LR (72 hour negative blood negative blood cultures at 48 cultures hours Afebrile for at least Afebrile for at least 24 hours, 24 hours Evidence of marrow recovery marrow recovery status @C@sameoere er eee ee en eae ene petite eee iii (=oeeacee [c=ere eee teen acne ee ame iad Risk Stratification eee + Monitoring of serum galactomannan (GM) twice per week for early diagnosis of invasive aspergillosis + Consider GM in BAL and cerebrospinal fluid to support the diagnosis of pulmonary or CNS aspergillosis (2017-> weak recommendation) + Computed tomography (CT) of the lungs and targeted imaging of other clinically suspected areas of infection iosmeco 16Perera nee a enna ete ea ene es Gee uta ies + Initiate empiric antifungal treatment for persistent or recurrent fever of unclear etiology that is unresponsive to prolonged (96 hours) broad- spectrum antibacterial agents + Use either caspofungin or liposomal amphotericin B (L-AmB) for empiric antifungal therapy 17e400 Inpatient VS outpatient renter) hospitalization etn) eects pathogens Deleterious psychological Pirrat Teutfel O, et al 2010 18Conclusions Sree Mees mene eleiteriey foetal teenies e Re ois Pie) eer Peete as@40300 Thank You