Abstract. This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that. Risk of febrile neutropenia (FN) should be systematically assessed (in consultation with infectious disease specialists as needed), including. Febrile neutropenia (FN) is a serious complication of cancer chemotherapy that The Infectious Diseases Society of America (IDSA), National.
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IDSA GUIDELINES Bundle (free trial) – Fever and Neutropenia
The American Journal of Managed Care. The American Journal of Accountable Care.
Compendia Alternative Payment Models. Precision Medicine in Oncology. The Relevance of Febrile Neutropenia in Oncology. Perspectives in Febrile Neutropenia: Febrile neutropenia FN is a serious complication of cancer chemotherapy that can lead to delays in treatment and necessary dose reductions of chemotherapy, which compromise treatment efficacy.
Due to reduced levels of neutrophils in circulation, patients with neutropenia may have an impaired ability to fight infections. It is crucial to monitor patients for signs and symptoms of infection, which may present as fever, chills, or sweats. Other signs and symptoms of infection for patients with FN are provided in Table 1. Fever may be the sole indicator of an underlying infection in patients with chemotherapy-induced neutropenia; other signs and symptoms of inflammation may be absent.
Because patients with FN may have minimal or absent symptoms of bacterial infections, detection requires close examination of the most commonly infected sites. Patients with FN are initially investigated for infection on sites of previous procedures or catheters, as well as on or in the skin, alimentary tract, oropharynx, gastrointestinal tract, lungs, genitourinary region, and respiratory system. Chest radiography may be indicated if there are any signs and symptoms of respiratory infection; this is to rule out pneumonia, which can progress rapidly in patients with FN.
Additionally, patient history iesa be analyzed for past positive microbiology records, specifically the presence of antibiotic-resistant organisms or bacteremia. Cultures should be obtained from suspected sites of infection for appropriate microbiological testing prior to empirical antimicrobial therapy. Urinalysis and sputum and stool cultures may be necessary in patients with suspected infection in the associated sites.
At least 2 sets of blood cultures are recommended, 1 from a central venous catheter and 1 neutfopenia a peripheral vein.
IDSA GUIDELINES Bundle (free trial)
However, if no central venous catheter is available, 2 sets of cultures may be taken from separate venipunctures for the detection of bloodstream pathogens. Renal and liver function are routinely investigated during the initial assessment for serum creatinine levels, blood urea nitrogen, electrolytes, hepatic transaminase enzymes, and total bilirubin to plan supportive care and appropriate treatment.
Depending on the level of risk determined, management of patients may vary in the administration of treatment oral or intravenousduration of therapy, and treatment setting outpatient or hospital.
Additional factors that idsx the risk of complications for patients with FN following cancer chemotherapy are summarized in Table 2. The MASCC index neutropeni values to patient age, history, outpatient or inpatient status, clinical signs, severity of fever and neutropenia, and presence of medical comorbidities; the summation of those values determines risk classification. Low-risk patients are initially treated with oral or intravenous empiric therapy.
In addition, high-risk patients may have clinically relevant comorbidities such as hypotension, pneumonia, new onset of abdominal pain, renal or hepatic insufficiency, or neurological changes.
Guidelines in the Management of Febrile Neutropenia for Clinical Practice
Patients with FN at high risk of serious complications are treated with intravenous empiric antibiotic therapy in the inpatient setting. Patients with FN with high risk of feebrile should be initiated with empiric antibiotics administered intravenously in the hospital setting.
Clinical practice guidelines from the IDSA recommend initial antibiotic monotherapy including an antipseudomonal beta-lactam ie, cefepimea carbapenem ie, meropenem, imipenem, or cilastatinor piperacillin-tazobactam. Patients who are afebrile and develop signs and symptoms of infection should also be treated empirically with the same regimen as high-risk patients.
Initial treatment with vancomycin and other antibiotics effective against gram-positive cocci are not recommended as standard empirical antibiotic treatment for patients with FN. However, these agents may be considered in modifications of initial treatment as additional therapy for patient-based needs, such as suspicion of catheter-related infection, skin or soft-tissue infection, pneumonia, hemostatic instability, or antibiotic resistance.
If methicillin-resistant Staphylococcus aureus is suspected, the initial antibiotic regimen can be modified to include vancomycin, daptomycin, or linezolid. Suspicion of vancomycin-resistant enterococcus calls for the addition of linezolid or daptomycin. If extended-spectrum beta-lactamase—producing gram-negative bacteria is suspected, patients may benefit from the early use of carbapenem.
The addition of polymyxin-colistin or tigecycline to the early treatment netropenia appropriate if the presence of Klebsiella pneumoniae carbapenemase-producing bacteria is suspected. Patients allergic to penicillin may be given cephalosporin, but either ciprofloxacin and clindamycin or aztreonam and vancomycin are recommended in cases isa immediate hypersensitivity. Patients meeting select criteria of clinical stability and adequate gastrointestinal absorption may be eligible for treatment switch from intravenous to oral administration of antibiotics.
Recommended treatment for low-risk patients includes combination oral antibiotic therapy with ciprofloxacin and amoxicillin-clavulanate. Other orally administered regimens commonly used in clinical practice are monotherapy with levofloxacin or ciprofloxacin and combination with ciprofloxacin and clindamycin. If a patient is being treated for FN with fluoroquinolone prophylaxis, a fluoroquinolone cannot be used as an initial empiric therapy.
Additionally, selected patients who are at low risk for complications and have family support and appropriate culture status may be eligible for transitioning treatment with intravenous or oral empiric therapy to the outpatient setting. Patients who continue to present with fever and worsening signs and symptoms of infection are to remain in hospital rather than being discharged.
Initiation of empiric antifungal therapy is recommended for patients who continue to have persistent fever of unidentified cause following 4 to 7 days of antibiotic treatment, and who present with neutropenia that is expected to last more than 7 days.
In patients with FN who are already receiving anti-mold prophylaxis, the switch to an agent in a different antifungal class should be considered. However, there are insufficient data to determine which antifungal agent is most appropriate. Daily assessments include laboratory tests and cultures for infection, fever trends, and toxicity of treatment.
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