UCONN Emergency Medicine Interest Group

Off Service #2: Heme/Onc

In OFF SERVICE on August 26, 2011 at 7:00 AM

Dr. Gilcrease, Heme/Onc Fellow, University of Utah/Huntsman Cancer Institute

Approach towards neutropenic fever

1. Identify using definitions:

  • ANC < 500 (or will be <500 in 48 hrs, but this is difficult for EPs to determine). Profound neutropenia is ANC < 100. Note: this count includes neutrophils and bands (but not more immature cells).
  • Fever = any T>38.3 (101 F), or T>38 (100.4) for >1 hr. Note: the elderly and pts on corticosteroids may not mount a fever! Also, remember that not all fever = infection.

2. Risk stratify

  • Hisk risk by IDSA 2010 criteria: ANC<100 for >7 days, comorbidities (including GI sx, neuro sx, central venous catheter infection, etc.), hepatic injury (transaminases >5x upper limit of normal), renal insufficiency (CrCl<30)
  • Alternative risk stratification is the MASCC score, but this is more complicated; if used, score >=21 is high risk.
  • If high risk, hospitalize and give IV abx.
3. Initial management
  • Exam- be thorough, do not forget skin, mucosal, port-a-cath, central lines, wounds, abdominal exam. Remember that neutropenic pts frequently will not show signs of infection (eg. abscess, induration, warmth, pulmonary infiltrate). DO NOT do a rectal exam (may cause a bacteremia).
  • Labs- CBC, CMP, UA, directed imaging, blood cx from central venous catheter if present and 2 peripheral sites, directed tests as needed (eg. LP, wound cx, CDiff toxin, stool cx).
  • Abx: within 2 hrs of presentation.
    • Outpatient: cipro/augmentin or levofloxacin
    • Inpatient: meropenem +/- vancomycin
      • If any mucosal breakdown, skin breakdown, concern for central-line infection, pneumonia, give a dose of vanco.

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