Summary
Definition
History and exam
Key diagnostic factors
- quimioterapia recente
- febre
Other diagnostic factors
- idade >65 anos
- terapia imunossupressora (TI)
- neutropenia induzida por quimioterapia prévia
- capacidade funcional baixa (capacidade funcional do Eastern Cooperative Oncology Group [ECOG PS] >1)
- neoplasias hematológicas
- doença em estágio avançado
- esquemas de antibioticoterapia prévios
- albumina baixa (<35 g/L [<3.5 g/dL])
- bilirrubina e enzimas hepáticas elevadas (aspartato aminotransferase e fosfatase alcalina)
- disfunção de órgãos e comorbidades preexistentes
- baixa contagem absoluta de neutrófilos no nadir do primeiro ciclo (<500 células/microlitro)
- sinais de pneumonia (tosse, ruídos adventícios, dispneia)
- dor abdominal
- náuseas ou vômitos
- diarreia
- eritema cutâneo, pele quente, sensibilidade
- mucosite ou úlceras orais
- infecção, inflamação ou ulceração das áreas genital e anal
- cateteres de demora infectados
- piúria
- quimiorradioterapia
- características históricas e exposições recentes
- sensibilidade do seio nasal
Risk factors
- idade >65 anos
- neoplasias hematológicas
- albumina baixa (<35 g/L [<3.5 g/dL])
- bilirrubina elevada
- enzimas hepáticas elevadas
- disfunção de órgãos e comorbidades preexistentes
- quimioterapia recente
- baixa contagem absoluta de neutrófilos no nadir do primeiro ciclo (<500 células/microlitro)
- quimiorradioterapia
- neutropenia induzida por quimioterapia prévia
- sexo feminino
- capacidade funcional baixa (capacidade funcional do Eastern Cooperative Oncology Group [ECOG PS] >1)
- doença em estágio avançado
- terapia imunossupressora (TI)
Diagnostic tests
1st tests to order
- hemograma completo e diferencial
- urinálise e testes da função renal (ureia e creatinina)
- testes da função hepática
- hemoculturas
- radiografia torácica
Tests to consider
- ensaio molecular de patógenos gastrointestinais
- urocultura
- punção lombar
- culturas fúngicas e sorologias (beta-glicano e galactomanano)
- ensaio molecular viral
- ecocardiograma
- tomografia computadorizada (TC) do tórax, abdome e pelve
Treatment algorithm
alto risco de complicação ou morte: apresentação inicial
baixo risco de complicação ou morte: apresentação inicial
febre persistente além de 3-5 dias de tratamento
Contributors
Authors
Lynne Strasfeld, MD
Professor of Medicine
Department of Medicine, Division of Infectious Diseases
Oregon Health and Science University
Portland
OR
Disclosures
LS declares that she has no competing interests.
Acknowledgements
Dr Lynne Strasfeld would like to gratefully acknowledge Dr Kenneth V. I. Rolston, Dr Lior Nesher, Dr Caron Jacobson, and Dr Joseph Antin, previous contributors to this topic.
Disclosures
KVIR has research grants from Merck, Shionogi, and JMI Laboratories for the performance of in vitro studies of novel antimicrobial agents. LN has given two educational lectures sponsored by MSD. CJ and JA declare that they have no competing interests.
Peer reviewers
Alison Freifeld, MD
Professor of Medicine, Infectious Diseases Division
University of Nebraska College of Medicine
Omaha
NE
Disclosures
AF has received payment by Merck for work as an adjudication committee member for clinical trials of letermovir. AF has received an investigator-initiated study grant from Merck.
John Wingard, MD
Price Eminent Scholar and Professor of Medicine
Director
Bone Marrow Transplant Program
Division of Hematology/Oncology
University of Florida College of Medicine
Gainesville
FL
Disclosures
JW has been reimbursed by Pfizer, Merck, Astellas, and Enzon for speaking fees, fees for educational programs, and consulting.
Matthew Falagas, MD, MSc, DSc
Director
Alfa Institute of Biomedical Sciences
Marousi
Athens
Greece
Disclosures
MF declares that he has no competing interests.
Ruth Pettengell, MBChB FRACP PhD
Senior Lecturer in Haematology
Honorary Consultant in Medical Oncology
St George's University of London
London
UK
Disclosures
RP has received speaker fees and been reimbursed by Roche, Amgen, Chigai, and Bayer for attending several conferences. RP is a co-author of the EORTC guidelines referenced in this topic.
References
Key articles
Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011 Feb 15;52(4):e56-93.Full text Abstract
Smith TJ, Bohlke K, Lyman GH, et al. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2015 Oct 1;33(28):3199-212.Full text Abstract
Klastersky J, de Naurois J, Rolston K, et al. Management of febrile neutropaenia: ESMO Clinical Practice Guidelines. Ann Oncol. 2016 Sep;27(5 suppl):v111-8.Full text Abstract
Taplitz RA, Kennedy EB, Bow EJ, et al. Outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America clinical practice guideline update. J Clin Oncol. 2018 Feb 20;36(14):1443-53.Full text Abstract
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: prevention and treatment of cancer-related infections [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Febre medicamentosa
- Febre tumoral
- Tromboembolismo
More DifferentialsGuidelines
- Prevention and treatment of cancer-related infections
- Hematopoietic growth factors
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