Neutropenia febril

2,776 views

Published on

Published in: Health & Medicine, Technology
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,776
On SlideShare
0
From Embeds
0
Number of Embeds
957
Actions
Shares
0
Downloads
113
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • En los pacientes de bajo riesgo se evalua ambulatorio vs internado, oral vs endovenoso. Se tratan de poblaciones heterogeneas con pocas complicaciones
  • Inpatient versus outpatient—Forest plot of treatment failure. Squares to the left of the vertical line indicate a decreased risk of developing treatment failure in patients receiving inpatient management. Horizontal lines through the squares represent 95% confidence intervals (CIs). The diamonds represent the overall risk ratio (RR) from the meta-analyses and the corresponding 95% CIs.
  • Intravenous versus oral treatment in ambulatory care—Forest plot of treatment failure. Squares to the left of the vertical line indicate a decreased risk in developing treatment failure in patients receiving intravenous antibiotics. Horizontal lines through the squares represent 95% CIs. The diamonds represent the overall risk ratio (RR) from the meta-analyses and the corresponding 95% confidence intervals. p.o. = oral.
  • Scoring index for identification of low-risk febrile neutropenic patients at time of presentation with fever.
  • Zinner SH . Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. Clin Infect Dis 1999;29:490-4. Abstract/FREE Full Text ↵ Wisplinghoff H, Seifert H,Wenzel RP, et al . Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasms in hospitals in the United States. Clin Infect Dis 2003;36:1103-10. Abstract/FREE Full Text
  • Initial management of fever and neutropenia. *Limited data to support recommendation. ANC, absolute neutrophil count; CT, computed tomography; MRI, magnetic resonance imaging.
  • Reassess after 2-4 days of empirical antibiotic therapy. ANC, absolute neutrophil count; CT, computed tomography; IV, intravenous; MRI, magnetic resonance imaging.
  • High-risk patient with fever after 4 days of empirical antibiotics. C. difficile, Clostridium difficile; IV, intravenous.
  • J antimicrob chemother 2011 66(2):251-259. Metaanalisis
  • Administration of granulocyte colony–stimulating proteins based on identified risk factors including older age, bone marrow involvement, radiation to marrow-producing sites (pelvis, sternum, ribs, calvarium, femurs), splenectomy or splenic irradiation in patients with extramedullary hematopoiesis, and Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 16 chemotherapeutic regimens known to induce myelosuppression has reduced the incidence of hospitalizations for febrile neutropenia. To be effective, however, the administration of growth factors requires patient and caregiver education regarding reportable signs and symptoms, a clear plan for discussion of laboratory values and symptoms, and implementation of a practicespecific plan for identification of patients at high risk and prevention strategies for those patients. Maintaining Adherence to Novel Oral Agents
  • Neutropenia febril

    1. 1. PABLO PARENTI NEUTROPENIA FEBRIL
    2. 2. <ul><li>>38.5º axilar </li></ul><ul><li>> 1 hora </li></ul><ul><li>< 500 neutrófilos </li></ul>
    3. 4. <ul><li>Evaluacion del riesgo </li></ul><ul><li>Exámenes complementarios </li></ul><ul><li>Antibioticoterapia inicial </li></ul><ul><li>Cuanto tiempo, profilaxis </li></ul><ul><li>Antifúngicos </li></ul><ul><li>Antivirales </li></ul><ul><li>Factores crecimiento de colonias </li></ul>
    4. 5. <ul><li>ALTO </li></ul><ul><li>BAJO </li></ul><ul><li>Internado </li></ul><ul><li>Endovenoso </li></ul><ul><li>Ambulatorio </li></ul><ul><li>Oral / Endovenoso </li></ul>Evaluación del riesgo > 7 dias de duración - < 100 neutrofilos – comorbilidades – 21 puntos MASCC
    5. 6. Inpatient versus outpatient—Forest plot of treatment failure. Teuffel O et al. Ann Oncol 2011;annonc.mdq745 © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com
    6. 7. Intravenous versus oral treatment in ambulatory care—Forest plot of treatment failure. Teuffel O et al. Ann Oncol 2011;annonc.mdq745 © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com
    7. 8. Scoring index for identification of low-risk febrile neutropenic patients at time of presentation with fever. Hughes W T et al. Clin Infect Dis. 2002;34:730-751 © 2002 by the Infectious Diseases Society of America
    8. 9. Estratificación de Riesgo al Ingreso © 2009 Clínica-UNR.org
    9. 11. Exámenes complementarios <ul><li>Laboratorios </li></ul><ul><li>Cultivos </li></ul><ul><li>Rx tórax </li></ul>
    10. 12. Foco © 2009 Clínica-UNR.org
    11. 13. Infecciones Microbiológicamente Detectadas. Resultados Positivos © 2009 Clínica-UNR.org
    12. 14. Hongos <ul><li>Cultivos más PCR </li></ul><ul><li>Pequeños trabajos de la industria con limitaciones metodológicas. </li></ul>
    13. 15. Antibioticoterapia inicial
    14. 16. Common Bacterial Pathogens in Neutropenic Patients <ul><li>Common gram-positive pathogens </li></ul><ul><li>Coagulase-negative staphylococci </li></ul><ul><ul><li>Staphylococcus aureus , including methicillin-resistant strains </li></ul></ul><ul><ul><li>Enterococcus species, including vancomycin-resistant strains </li></ul></ul><ul><li>Viridans group streptococci </li></ul><ul><ul><li>Streptococcus pneumoniae </li></ul></ul><ul><ul><li>Streptococcus pyogenes </li></ul></ul><ul><li>Common gram-negative pathogens </li></ul><ul><ul><li>Escherichia coli </li></ul></ul><ul><ul><li>Klebsiella species </li></ul></ul><ul><ul><li>Enterobacter species </li></ul></ul><ul><ul><li>Pseudomonas aeruginosa </li></ul></ul><ul><ul><li>Citrobacter species </li></ul></ul><ul><ul><li>Acinetobacter species </li></ul></ul><ul><ul><li>Stenotrophomonas maltophilia </li></ul></ul>
    15. 18. Initial management of fever and neutropenia. Freifeld A G et al. Clin Infect Dis. 2011;52:e56-e93 © The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:journals.permissions@oup.com.
    16. 19. Indications for Addition of Antibiotics Active Against Gram-Positive Organisms to the Empirical Regimen for Fever and Neutropenia <ul><li>Hemodynamic instability or other evidence of severe sepsis </li></ul><ul><li>Pneumonia documented radiographically </li></ul><ul><li>Positive blood culture for gram-positive bacteria, before final identification and susceptibility testing is available </li></ul><ul><li>Clinically suspected serious catheter-related infection (eg, chills or rigors with infusion through catheter and cellulitis around the catheter entry/exit site) </li></ul><ul><li>Skin or soft-tissue infection at any site </li></ul><ul><li>Colonization with methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococcus, or penicillin-resistant Streptococcus pneumoniae (see text) </li></ul><ul><li>Severe mucositis, if fluoroquinolone prophylaxis has been given and ceftazidime is employed as empirical therapy </li></ul>
    17. 20. Cuanto tiempo <ul><li>Según la etiología </li></ul><ul><li>Según la respuesta clínica </li></ul><ul><ul><li>Hasta que salga de la neutropenia </li></ul></ul><ul><ul><li>Si continúa neutropénica, fluorquinolonas profiláctica </li></ul></ul><ul><ul><ul><li>Pacientes de alto riesgo </li></ul></ul></ul><ul><ul><ul><li>No se cubre gram positivos </li></ul></ul></ul>
    18. 21. Reassess after 2-4 days of empirical antibiotic therapy. Freifeld A G et al. Clin Infect Dis. 2011;52:e56-e93 © The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:journals.permissions@oup.com.
    19. 22. High-risk patient with fever after 4 days of empirical antibiotics. Freifeld A G et al. Clin Infect Dis. 2011;52:e56-e93 © The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:journals.permissions@oup.com.
    20. 23. Unica vs multiples dosis de aminoglucósidos <ul><li>UD tendencia a mayor eficacia, pero no se observo en la población microbiologicamente evaluable </li></ul><ul><li>Seguridad y mortalidad similar </li></ul><ul><li>Muestras limitadas </li></ul>
    21. 24. Antigúngicos <ul><li>4-7 días de fiebre y más de 7 días de neutropenia </li></ul><ul><li>Problemas </li></ul><ul><ul><li>Fiebre por antibioticos </li></ul></ul><ul><ul><li>Profilaxis con antifúngicos (Aspergilosis: Posaconazol) </li></ul></ul><ul><ul><ul><li>LMA, SMD en >13 años qmt </li></ul></ul></ul><ul><ul><ul><li>Transplante medula autologo o alogénica, previa aspergilosis, >2 semana neutropenia. </li></ul></ul></ul>
    22. 25. Antivirales <ul><li>HSV (aciclovir). Transplante alogénico o inducción en leucemia en pacientes con serología positiva </li></ul><ul><li>Vacuna antiinfluenza </li></ul>
    23. 26. Factores crecimiento de colonias <ul><li>Uso profilactivo cuando el riesgo de nuetropenia es alto </li></ul><ul><li>El uso profilactico de factores de colonias disminuye las internaciones por neutropenia </li></ul>
    24. 27. cateter <ul><li>S. aureus, P. Aureginosa, Hongos o micobacterias: Remover. 14 días de tto </li></ul><ul><li>Stafilo coagulasa negativos: retener? </li></ul><ul><li>Complicaciones: EI, trombosis, partes blandas, bacteriemia, fungemia. Tto 4-6 semanas </li></ul>
    25. 29. PABLO PARENTI [email_address] GRACIAS

    ×