Managing Fever in the Presence of Neutropenia or Central Lines

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Managing Fever in the Presence of Neutropenia or
Central Lines

• Susan E. Haynes, MD
• July 20, 2007

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Fever and Neutropenia
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Muy Importante!

• Fever in a patient with cancer or on chemotherapy
  is a medical emergency
• Mortality is 1-5

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Definitions

• Fever
• Single oral Tgt101oF (38.3oC)
• OR
• T100.4oF (38oC) on two separate readings one
  hour apart
• Oral is best take axillary if oral temp
  impossible
• AVOID rectal temperature in any oncology patient
  at any time

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Definitions

• Neutropenia
• ANC lt 1500
• Mild 1500-1000
• Moderate 1000-500
• Severe lt500
• Profound lt200
• Risk of infection in cancer patients is high if
  ANClt1000

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Definitions

• Calculating the ANC
• Total WBC count x ( neutrophils bands)
• WBC 3.1, neutrophils 30, bands 4
• What is the ANC?
• WBC 2.4, neutrophils 0, bands 0
• What is the ANC?

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Risk

• Infection risk increases with
• Any break in the skin barrier
• Any foreign body central lines, indwelling
  ports, Foley catheters, NG tubes, shunts, rods,
  prostheses
• Prolonged neutropenia

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History

• Duration of fever? Accompanied by chills?
• Fatigue?
• Rhinorrhea?
• Cough?
• Abdominal pain or GI symptoms?
• Dysuria?
• Central line?

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Physical Exam

• Thorough exam, including
• Oral exam for ulcerations
• Perirectal exam for lesions
• Nares for lesions, especially if NGT feeds
• Skin exam
• Central line for phlebitis, cellulitis

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Admission Investigations

• CBC with diff, CRP, blood cultures from periphery
  x 1, blood cultures from all lumens of all
  central lines, CP14 (most chemo patients will
  have abnormalities)
• urinalysis and culture (must be clean
  catch--catheterization contraindicated in
  neutropenia)
• viral respiratory culture and rapid flu and RSV
  if indicated
• If diarrhea, C. diff toxin, fecal WBCs, stool
  culture

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Admission Investigations

• Radiologic Studies
• CXR (debatable if no pulmonary symptoms)
• Sinus CT if symptoms or if all other workup
  negative
• Abdominal CT if significant abdominal pain (worry
  about neutropenic colitis, aka acute typhilitis)

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Beware

• CXR may not have an infiltrate apparent during
  neutropeniamay change after counts recover
• Urinalysis may not have WBCs or leukocyte
  esterase during neutropeniasend a culture

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Daily Labs

• CBC with differential to follow ANC
• CRP if previously elevated
• CP14 if indicated (if needs supplements or on
  TPN)
• Blood cultures while febrile (can be from central
  line, dont have to have peripheral)

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0200

• You are called by a nurse. He has just seen your
  orders for a blood culture for Julie, a 2 yo
  female with neutropenia admitted with a fever.
  He already started her IV and drew her other labs
  before he saw the order for the blood culture.
  Is it OK if he draws some blood back off the IV
  for the culture so he doesnt have to stick her
  again?

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Medications

• Cefepime 50 mg/kg/dose IV Q8 hours, max dose 2
  grams/dose
• Add Vancomycin 10 mg/kg/dose IV Q6 hours (max 500
  mg/dose) if signs of line infection
• ID likes Ceftazidime and Vanc to start
• Add Gentamicin 5 mg/kg/day IV Q24 hours if
  hypotension and chills
• Add Amphotericin B if persistent neutropenia and
  fever gt4-5 days despite antibiotics
• Both Cefepime and Ceftaz can cause neutropenia,
  even in healthy people!

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To culture or not?

• Recollect blood cultures in these cases
• Before adding or changing an antibiotic
• Persistent fever (get one culture per day while
  febrile, best to get when actually febrile, dont
  always have to have a peripheral)
• During times of clinical deterioration
• If you are called with a positive culture
• You dont need 8 million cultures in a day!

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What if something grows?

• Order another culture
• Look at your antibiotics and see if you should
  have coverage
• Follow-up on the sensitivities should be
  available the next day
• Tailor antibiotics if possible
• If a true infection, ECHO

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Contaminant or Not?

• Unlikely to be true pathogens
• Corynebacterium, non-anthracis Bacillus,
  Propionibacterium acnes
• Uncertain significance
• Coagulase negative staph
• If your patient was unstable, has a CVL, or this
  grows in multiple cultures, maybe so!
• Probably so
• S. aureus, S. pneumo, Enterobacter, P.
  aeruginosa, C. albicans, Aspergillus

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Consider

• If multiple positive blood cultures, likelihood
  of true bacteremia increases
• If cultures are repeatedly positive for coag neg
  staph or if peripheral and CVL cultures are
  positive at the same time, likelihood of true
  bacteremia increases

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How long do you treat?

• Depends on the organism and if they have a
  central line that you want to keep
• Depends on initial clinical appearance
• Usually minimum of 14 days for CVL, sometimes
  longer ask your friendly ID expert!
• Start counting your days of antibiotics from the
  date the first negative cx was drawn, not from
  first day of antibiotics

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What if nothing grows?

• This will happen more often than not.
• You can stop antibiotics when
• Afebrile for 48 hours
• Counts recovered (ANC gt500)
• All cultures negative for 48-72 hours, and any
  positive cultures treated fully
• Clinically stable
• Your attending says so!

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Fever and Central Lines in the Absence of
Neutropenia
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Types of Central Lines

• Hickman catheter
• Seen more in infants and toddlers
• Placed surgically in the chest wall needs
  surginet
• Benefits always accessed, no needle stick to
  draw blood or infuse
• Drawbacks always accessed, increasing risk of
  infection, hanging on chest, gets pulled by
  frisky kids

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0100

• RN calls you because Ricky, a 3 yo with ALL, was
  found running in the hall with his IV pole behind
  him attached to his Hickman catheter. She thinks
  he might have pulled out the line some.
• What do you want to do?

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Other than installing a lock

• Inspect the chest for any changes
• Be sure that he has surginet over his trunk to
  secure line
• See if there is still blood return
• Get a CXR and compare it to previous placement
• If displaced, notify surgery team and discontinue
  use until repaired
• Dont keep kids hooked up if not necessary

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Types of Central Lines

• Port A Cath
• Seen more in older children and adolescents
• Surgically placed in the chest wall
• Benefits cannot be pulled on because its
  subcutaneous, theoretically less infection
• Drawbacks requires needle stick to access or
  draw labs, can flip and make access difficult

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2200

• You are called because 10 yo Heavens port is not
  drawing back blood or flushing. She says that it
  hurts her.
• What do you want to do?

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Try

• Deaccessing the port (need to flush with heparin
  before deaccessing in general)
• Applying EMLA cream for comfort with needle
  sticks
• Reaccessing the port
• If you cant get blood return, you cant use it
  unless you have a radiology dye study to verify
  placement (considered bad form to infuse chemo or
  most anything subcutaneously!)

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Types of Central Lines

• PICC Lines (Peripherally Inserted Central
  Catheter)
• Placed by specially trained team of RNs
• Benefits dont have to go the OR for placement,
  constant access, may be able to draw blood back,
  allows home IV abx
• Drawbacks requires weekly CXR for placement, not
  usually used for chemo, can break or migrate

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1400

• You need a CBC on a patient with a PICC line.
  Can the nurse draw it off the PICC line or do
  they have to stick the patient?
• Look at the original orders for the PICC line (in
  the order section). They tell you if you can
  draw off it or not. If you cant find them, ask
  the PICC team or use these general guidelines

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PICC Guidelines

• Can draw labs off 3 Fr and bigger
• Can transfuse blood through 3 Fr and bigger (risk
  of clotting off)
• No contrast administered unless by specially
  trained RN (makes radiology techs nervous)
• 1.9 Fr get heparin flushes Q4 hours and after use
  (unless really tenuous, then may get continuous
  heparin)
• 3 Fr and bigger get NS flushes only
• Dressing changes Q week and PRN nasty

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Muy importante!

• Fever in a child with a central line is
  bacteremia until proven otherwise

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History

• Why do they have a central line? Are they
  already on antibiotics at home? Which ones, what
  doses?
• Other sources of fever?
• Line care, any problems with lines, any rash,
  cellulitis, pain associated with line?
• Fever, chills, nausea, fatigue?

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Physical Examination

• Look at the line and look proximal to the line
  for any streaking, phlebitis
• Look for any other sources
• Listen for a murmur!

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Labs

• CBC with diff, CRP, blood culture from periphery
  and from all lumens of the central line
• Any applicable drug levels
• CP14 depending on the drugs that they are on
• Other investigations for fever as indicated

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Other studies

• CXR for placement if needed
• ECHO if murmur or a true positive blood culture
  to rule out endocarditis

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WARNING

• NEVER try to push fluids or put Cath-Flo in a
  central line that you think might be infected,
  you can release a septic emboli!
• NEVER treat any CVL infection with PO antibiotics
• ALWAYS give antibiotics through the CVL if
  functioning

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Medications

• Cefepime 50 mg/kg/dose (covers Pseudomonas, Gram
  negatives and MSSA)
• Vancomycin 10 mg/kg/dose IV Q6 hours (covers MRSA
  and coag neg staph)
• What do you write after your Vanc order?

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When should a line come out?

• For sure when there is a fungal infection
• Probably when there is a bacillus infection
• Otherwise, consult with ID regarding safety of
  treating line
• If patient unstable with a Gram negative
  infection, line has to come out, otherwise, may
  be able to treat
• Should complete treatment before another line is
  placed

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Consent for a PICC Line

• Risks
• Breakage inside the body 4/1000
• Breakage outside the body more frequent
• Infections very rare, almost 0 here
• Benefits
• Longer lasting access
• Can go home to complete IV antibiotics for
  infections like osteomyelitis