NEUTROPENIC FEVER
Approach
• Initiate access, IVFs, abx, & tx of sepsis as early as possible. Pts can deteriorate quickly.
Definition
• Single temp >38.3°C or temp >38°C for 1 h + ANC <500, or <1000 + predicted drop <500, or functionally neutropenic (eg, AML)
• Pts may experience rapid clinical deterioration w/ few presenting signs of inflammation
History
• Date of fever onset, date of cytotoxic therapy (ANC nadir ∼10–14 d after chemo)
Findings
• Examine skin, mouth, lung, abdomen, catheter/surgical sites, perirectal area (DRE)
Evaluation
• CBC w/ differential, Chem 7, LFTs, coags, UA/urine cx, blood cx (at least 2 + any catheter port if present), ±CXR
• ±Additional labs: Coags, culture (stool/sputum/peritoneal/CSF)
• Imaging: Consider imaging of chest, abdomen/pelvis, sinuses, brain
Treatment
• Empiric abx → low risk: Ciprofloxacin + (amoxicillin + clavulanate)
• Empiric abx → high risk: AFTER cx are drawn, cover for resistant Pseudomonas:
• Monotherapy: Ceftazidime, cefepime, or carbapenem (except ertapenem)
• Combination (synergy against GNRs): Aminoglycoside + antipseudomonal PCN or any of the monotherapy drugs
• Vancomycin: For catheter-related infxn, MRSA colonization, ↓ BP
• PCN-allergic → levofloxacin + aztreonam or aminoglycoside
• Antivirals: Acyclovir (if skin lesions c/w herpes/VZV)
Disposition
• Low threshold to admit all pts w/ neutropenic fever
Pearls
• ≥50% pts w/ neutropenic fever have occult infection & ∼60–70% are gram+ (Clin Infect Dis 2002;34:730)
• Atypical organisms, meningitis are rare
TUMOR LYSIS SYNDROME (Oncology 2011;25(4):378)
Approach
• Obtain ECG immediately (look for signs ↑ K), & put on cardiac monitor
Definition
• Rapid destruction neoplastic cells → release of intracellular uric acid, K, PO4
• Defined as ≥2 of abnl serum values (>25% ↑ K, ↑ PO4, ↓ Ca) w/i 3 d before or 7 d after the start of chemotherapy & ≥1 of renal failure (GFR ≤ 60), cardiac arrhythmia, or sz
• Typically 48–72 h after starting cytotoxic cancer tx, a/w large, rapidly proliferating, tx-responsive tumors (esp acute leukemia, NHL, Burkitt)
History
• N/V, lethargy, edema, CHF, hematuria, cardiac dysrhythmia, sz, muscle cramps, tetany, syncope, sudden death
Evaluation
• Chem 7, Ca, PO4, uric acid, BUN/Cr, LDH, UA (urine pH) → ↑ uric acid, ↑ K, ↑ PO4, ↓ Ca; uric acid must be drawn on ice
Treatment
• Treat ↑ K/↑ PO4 & symptomatic ↓ Ca
• IVFs/hydration to maintain UOP > 100 mL/h: Pts typically have ↓ vascular volume
• Isotonic sodium bicarbonate → urine alkalinization → prevents renal precipitation of uric acid
• Allopurinol
• Rasburicase: In consultation w/ oncology → promotes metabolism of uric acid, may reduce need for dialysis, do not give concomitant allopurinol (J Clin Oncol 2001;19:697)
• HD: If persistent ↑ K, severe acidosis, volume overload, uremia, severe ↑ PO4 or ↓ Ca
Disposition
• Admit (floor vs. ICU, depending on severity)