MDM ANG B - Nigel Fong€¦ · · 2017-09-10MDM ANG B.C Evelyn Wong ... , IE not R/O), Undrained abscesses, Indwelling prosthesis ... You are now the clerking HO and

MDM ANG B.CEvelyn Wong

http://tinyurl.com/y9dl67my

Mdm Ang BeeChanisa55-year-oldChineseFemalewhoisADLindependentandcommunityambulant.Sheisanonsmokerandnonalcoholic.Herpremorbids includeT2aN1M0StageIIBLeftBreastCancerER-,PR+,Her2-ve,status-postmastectomyandaxillaryclearanceandiscurrentlyonadjuvantchemotherapy.SheiscurrentlyundergoingDoxorubicinandCyclophosphamideQ3weeklyfor4cyclesviaaCentralCatheterLine.Herotherpremorbids includeprevioushaemorrhoids andhypertensiononamlodipine5mg.

Shepresentswitha2dayshistoryoffeverofmax37.8aswellasbreathlessnessonwalking.Thereisnochestpainorpalpitations,nodiaphoresis.Shecomplainsofamildcoughandsorethroat.Onexamination,hervitalsareBP110/67,HR60,RR22,SpO295%onRA.Temp38.0.Sheisalertandspeakingfullsentences,conjunctivaearepale.Sheislookingalittlelethargicaswell.HS1S2noaudiblemurmurs.Lbilaterallyairentryintactnoobviouscrepitations.Asoftnontender.

YouaretheEmergencyMO,whataresomeofthekeyexaminations/investigationsyouwouldliketodo?(Choose5outof11)ABGStat FullBloodCountwithdifferentialcounts RenalPanelLiverPanel PeripheralBloodCultureX1 PeripheralBloodculture(peripheral+line)DRE CXR CTThorax UrineDipstick



YouaretheEmergencyMO,whataresomeofthekeyexaminations/investigationsyouwouldliketodo?(Choose5outof11)ABGStat FullBloodCountwithdifferentialcounts RenalPanelLiverPanel PeripheralBloodCultureX1 PeripheralBloodculture(peripheral+line)DRE CXR CTThorax UrineDipstick

APPROACH TO COUGHAcute < 3 weeks

Subacute3-8 weeks

Chronic >8 weeks

Respi « URTI« Asthma exac« COPD exac« Acute bronchitis « PE« Pneumonia

« Post infective « Other

acute/chronic causes

« PND *commonest cough (allergic rhinitis)

« Chronic bronchitis/ COPD« Cough variant asthma« Bronchiectasis « Tb « Malignancy « Pulmonary fibrosis « Recurrent aspiration « Sarcoidosis

Cardio « APO« Decompensation

« Heart failure

Others « Drugs « Croup « ALTB« Foreign body

« Drugs – Ace i« GERD « Chemical/ Occupational« Smoker’s cough« Psychogenic

To rule out (Red flags)

« PE« APO« Pneumonia

« Malignancy « TB

Aetiology

APPROACH TO FEVER AetiologyDisorder Common Uncommon RareMalignancy10-30%

Lymphoma Hypernephromas

Preleukaemias/ myelodysplastic syndromesHepatomasMyeloproliferative disorderMetastases to liver

Atrial myxomaMultiple myelomaCNS tumoursRenal cell caPancreatic caColon caSarcomas

Infections20-40%

including inadequately treated infx

TuberculosisIntra-abd abscessSubacute bacterial endocarditisTyphoidMalaria Prostatitis

EBVCMV Splenic abscessAbscessesOsteomyelitisCat scratch feverProstatitis

Chronic sinusitisVertebral osteomyelitisBrucellosis HistoplasmosisLyme diseaseHIV

Rheumatologic15-20%

Still’s diseasePolymyalgia rheumatica

RA SLEKikuchi’s diseaseBehcet’s diseaseTemporal arteritisRheumatoid feverIBD

Misc10-25%

Drug feverHabitual hyperthermia

Pulmonary embolism HaematomaFamilial fevers Hyperthyroidism

PhaeochromocytomaAdrenal insufficiency Liver cirrhosisDeep vein thrombosisSarcoidosis Factitious feverCardiac myxoma

FEVEREstablish patient group

■ Community acquired

■ Nosocomial

■ Immunocompromised

■ Returning traveler

■ Drug fever

■ Post-transfusion

■ Post-op

■ Fever in patient with foreign body (indwelling catheters, vp shunt, metallic valve)

FEVERFeverhistoryHeight,duration,frequency,associatedchillingorsweatsFeverpattern/descriptionUseofantipyretics– doesithelp?

Localizingsymptomsofinfection/systemicreviewSystemsreview:infective/connectivetissue/malignancy/drugs/miscLocalizingsymptomsofinfxJointpainLymphadenopathyCalfswelling,pain,redness– dvtConstitutional:nightsweats,fever,weightlossTravelhistory/ContacthistoryTravel:destination,durationofstay,dateofreturn,(mayworkoutincubationperiod)prophylaxis,pre-travelvaccinations,hygienelevel,freshwater,food,contactwithanimalsunprotectedsex

Drug(drugsmaycausefever)Antibioticuse– isoniazid,penicillin,erythromicin,Chemotherapy,Others:allopurinol,heparin,procainamide,phenytoin,

PmhxRecenthospitalizationForeignbodyinsitu/linesMalignancy- lymphomaChronicillnessesPreviousinfections/recurrentinfx:MSSA/MRSA(ifnotadequatelyRx,IEnotR/O),Undrainedabscesses,Indwellingprosthesis(includingAVGs),RecurrentUTIandkidneystonesVaccinationImmunosuppression:oldage,DM,malignancy(lymphoma,leukemia,myeloma),chronicsteroids,immunosuppressants andorganrecipients,AIDS,asplenia&complementdefectsSurgeries:Turp,Dentalextraction

Socialhistory:Occupation,Hobbies+interest,SexualHx

Familyhx:Familialfevers

Previousmanagement:Includingabx,antipyretics



WHO– 55,ECOGgood,Fit.Malignancys/pcurativeoperation.

WHAT– Fever.Coughandsorethroat

WHY– ?Infection

WHEN– 2days

HOW– SickorNotSick?!

Patientwassubsequentlybroughtuptotheward.YouarenowtheclerkingHOandyouareseeingthispatientforthefirsttime.Sheisabletogiveyouafullhistory.Shecomplainsofhavingacoughandsorethroatforabout3daysduration.NotedtohavefeverathomeofTMax 38.0.Hasbeendrinkingwaterbutduetothepaininherthroat,ithasbeendifficult.AbletoPUandBOwithnodifficulties,occasionallybloodstainedduetoherhaemorrhoids.Shehasnonauseanovomitting Herlastchemotherapywas1weekago.Astheon-callHO,youaresenttoclerkthepatient,kindlyanswerthebelowquestionsinshortanswers.

ShetellsyouthatshehastheCVClineinherforabout2monthsnowforherbloodtakingandchemotherapySheexplainedthatthisisher3rdcycleofchemotherapyHR nowis95,RR22,T38.0BP110/50LungauscultationrevealsintermittentcrepitationsHS1S2nomurmurBasiclaboratorystudiesperformedbytheA&Ereveal:

Hb 7.2(frompreviousbaselineof10.2)TW1.45AbsoluteNeutrophilCount0.73Plt 55

Anelectrocardiogramshowssinustachycardia.TheCXRisshownbelow.

Q3.Whatisthediagnosisforthepatient?(Answerbrieflyin1/2words)

Na137K3.8Cl104HCO322Cr50,CrtCL >100Troponinsnormal

■ A irway■ B ones■ C ardiac■ D iaphragm■ E ffusion■ F ields (lung)■ G astric bubble■ H ilum

/mediastinum

ShetellsyouthatshehastheCVClineinherforabout2monthsnowforherbloodtakingandchemotherapySheexplainedthatthisisher3rdcycleofchemotherapyHRnowis95,RR22,T38.0BP110/50LungauscultationrevealsintermittentcrepitationsHS1S2nomurmurBasiclaboratorystudiesperformedbytheA&Ereveal:

Hb 7.2(frompreviousbaselineof10.2)TW1.45AbsoluteNeutrophilCount0.73Plt 55

Anelectrocardiogramshowssinustachycardia.TheCXRisshownbelow.

Q3.Whatisthediagnosisforthepatient?

Na137K3.8Cl104HCO322Cr50,CrtCL >100Troponinsnormal

FEBRILE NEUTROPENIA

Fever T>38.3 once or T>38 for more than 1h

ANC <500 (or <1000 predicted to drop<500)

Usually happens 10-14 DAYS AFTER CHEMO (dep on regimen)

MEDICAL EMERGENCY

Potentially fatal if not treated appropriately

Febrile neutropenia

CommonsideeffectofchemotherapyLowneutrophilsà immunocompromisedANC<1.0x109/Là neutropeniaANC<0.5x109/Là severeneutropenia

Don’tbecaughtoutbyTotalWBCà calculatetheANC

WHAT BLOODS SHOULD I DO?IDSA Guidelines: Neutropenic FeverFBC+UECR+LFT

Atleast2setsofbloodculturesarerecommended,withasetcollectedsimultaneouslyfromeachlumenofanexistingcentralvenouscatheter(CVC),ifpresent,andfromaperipheralveinsite;2bloodculturesetsfromseparatevenipuncturesshouldbesentifnocentralcatheterispresent(A-III).

Bloodculturevolumesshouldbelimitedto,1%oftotalbloodvolume(usually>70mL/kg)inpatientsweighing,40kg(C-III).

Culturespecimensfromothersitesofsuspectedinfectionshouldbeobtainedasclinicallyindicated(A-III).

Achestradiographisindicatedforpatientswithrespiratorysignsorsymptoms(A-III).

Q4.Astheon-callHO,whichofthefollowingtherapies

wouldyouinitiate?(Choose3of10)FluidchallengewithNacl 0.9%1.5L Fluidchallengewith5%Albumin

NebSalbutamol FungalCulture

StartIVCeftriaxonewithPODoxycycline StartIVCefepime

StartIVAztreonam Transfuse500mlFFP

Transfuse1unitofpackedredbloodcells StartSubcutaneousGCSF

Q4.Astheon-callHO,whichofthefollowingtherapies

wouldyouinitiate?(Choose3of10)FluidchallengewithNacl 0.9% Fluidchallengewith5%Albumin

NebSalbutamol FungalCulture

StartIVCeftriaxonewithPODoxycycline StartIVCefepime

StartIVAztreonam Transfuse500mlFFP

Transfuse1unitofpackedredbloodcells StartSubcutaneousGCSF

SURVIVING SEPSIS

SURVIVING SEPSIS: Fluid

WHAT ABX SHOULD I GIVE?IDSA Guidelines: Neutropenic FeverHigh-riskpatientsrequirehospitalizationforIVempiricalantibiotictherapy;monotherapywith■ anantipseudomonalb-lactamagent,suchascefepime,acarbapenem

(meropenem orimipenem-cilastatin),orpiperacillin-tazobactam,isrecommended(A-I).

■ Otherantimicrobials(aminoglycosides,fluoroquinolones,and/orvancomycin)maybeaddedtotheinitialregimenformanagementofcomplications(eg,hypotensionandpneumonia)orifantimicrobialresistanceissuspectedorproven(B-III).

ROLE OF GCSFFilgrastim is a growth factor that stimulates the production, maturation, and activation of neutrophils (a type of white blood cell).

Filgrastim also stimulates the release of neutrophils from the bone marrow.

In patients receiving chemotherapy, filgrastimcan accelerate the recovery of neutrophils, reducing the neutropenic phase (the time in which people are susceptible to infections).

WHAT ABOUT GCSF?IDSA Guidelines: Neutropenic FeverProphylacticuseofmyeloidCSFs(alsoreferredtoashematopoieticgrowthfactors)shouldbeconsideredforpatientsinwhomtheanticipatedriskoffeverandneutropeniais>20%(A-II).

CSFsarenotgenerallyrecommendedfortreatmentofestablishedfeverandneutropenia(B-II).

Bythenextmorning,theprimaryteamhasarrivedandisseeingthepatient.Itturnsoutthatyouhavebeenallocatedtooncologyafteryourcallandnowyouarethepatient'smaindoctor.Whenyouassessthepatientagainaftergivinghertheantibiotics,hersaturationscontinuedtoworsenSheisnotspeakinginshortphrases.Thereisnoaudiblewheezehowevertherearebilateralcrepitations.Despitegivingherantibiotics,shecontinuetofeelbreathless.Theimpressionfromtheprimaryteamnowis:NeutropenicSepsis

Q5.AllofthefollowinginvestigationsarereasonabletoorderedEXCEPT(Choose1):

Bronchoscopy ColonoscopyCTThorax CoagulationProfileTransthoracicEchocardiogram

Bythenextmorning,theprimaryteamhasarrivedandisseeingthepatient.Itturnsoutthatyouhavebeenallocatedtooncologyafteryourcallandnowyouarethepatient'smaindoctor.Whenyouassessthepatientagainaftergivinghertheantibiotics,hersaturationscontinuedtoworsenSheisnotspeakinginshortphrases.Thereisnoaudiblewheezehowevertherearebilateralcrepitations.Despitegivingherantibiotics,shecontinuetofeelbreathless.Theimpressionfromtheprimaryteamnowis:NeutropenicSepsis

Q5.AllofthefollowinginvestigationsarereasonabletoorderedEXCEPT(Choose1):

Bronchoscopy ColonoscopyCTThorax CoagulationProfileTransthoracicEchocardiogram

Additionally,theuseofrectalthermometers,enemas,suppositories,andrectalexamsarecontraindicatedamongHSCTrecipientstoavoidskinormucosalbreakdown(DIII).

Whileyouarerushingwithallyourbusiness,andrunningaroundinthewards,shesuddenlystopsyouandcomplainsaboutthissorethroatandcoughthatsheisveryirritatedby.Youlookedintoheroralcavity.

Q6:Whatwillyoustartheron?(Choose1)

OralbicarbonatetabletsLignocaine1%MouthwashLozengesNystatinMouthwashOralSeven Moisturing MouthwashOralfluconazole

Whileyouarerushingwithallyourbusiness,andrunningaroundinthewards,shesuddenlystopsyouandcomplainsaboutthissorethroatandcoughthatsheisveryirritatedby.Youlookedintoheroralcavity.

Q6:Whatwillyoustartheron?(Choose1)

OralbicarbonatetabletsLignocaine1%MouthwashLozengesNystatinMouthwashOralSeven Moisturing MouthwashOralfluconazole

Mdm Ang continuedtodowellinpatientunderyourcare.Shewasstartedprompty on

antibioticsandherrecoveredgradually.Intheward,shecontinuestochatwithyou.

Onelifesaved.

Q7.Inadditiontopharmacologicaltherapy,youwouldadviseallofthefollowing

EXCEPT(Choose1)

Eatonlycookedfood

Wearamaskwheneveryougoout

Limittheamountofpeoplewhovisitsyou

Isolatethepatientinanegativepressureroom

Maintaingoodoralhygiene

Mdm Ang continuedtodowellinpatientunderyourcare.Shewasstartedprompty on

antibioticsandherrecoveredgradually.Intheward,shecontinuestochatwithyou.

Onelifesaved.

Q7.Inadditiontopharmacologicaltherapy,youwouldadviseallofthefollowing

EXCEPT(Choose1)

Eatonlycookedfood

Wearamaskwheneveryougoout

Limittheamountofpeoplewhovisitsyou

Isolatethepatientinanegativepressureroom

Maintaingoodoralhygiene

XII.WhatEnvironmentalPrecautionsShouldbeTakenWhenManagingFebrileNeutropenicPatients?

Recommendations• Handhygieneisthemosteffectivemeansofpreventingtransmissionof

infectioninthehospital(A-II).• Standardbarrierprecautionsshouldbefollowedforallpatients,and

infection-specificisolationshouldbeusedforpatientswithcertainsignsorsymptoms(A-III).

• HSCTrecipientsshouldbeplacedinprivate(ie,singlepatient)rooms(B-III).AllogeneicHSCTrecipientsshouldbeplacedinroomswith.12airexchanges/handHEPAfiltration(A-III).

• Plantsanddriedorfreshflowersshouldnotbeallowedintheroomsofhospitalizedneutropenicpatients(B-III).

WHAT CAN I DO TO PREVENT?IDSA Guidelines: Neutropenic Fever

BONUSQUESTIONSMdm Ang wasofficiallydischargedfromthehospitaltheresoon

afterandshewentaboutherdailychores.Howeverwhenyouwenthomethatnight

shewasdischarge,youhadthreeseparatedreamsandthesewerethedreamsthatyou

had.Whatwouldyoudointhosesituations

Q7a:Inyourfirstdream,Mdm Ang continuedtospiketemperaturedespitebeingon

IVCefepime for4days.Whichantibioticswouldyouaddon?(Choose1)

Amikacin Azithromycin

Tamiflu Doxycyclin

Vancomycin Imipenem

Tigecycline

BONUSQUESTIONSMdm Ang wasofficiallydischargedfromthehospitaltheresoon

afterandshewentaboutherdailychores.Howeverwhenyouwenthomethatnight

shewasdischarge,youhadthreeseparatedreamsandthesewerethedreamsthatyou

had.Whatwouldyoudointhosesituations

Q7a:Inyourfirstdream,Mdm Ang continuedtospiketemperaturedespitebeingon

IVCefepime for4days.Whichantibioticswouldyouaddon?(Choose1)

Amikacin Azithromycin

Tamiflu Doxycyclin

Vancomycin Imipenem

Tigecycline

WHEN SHOULD I ADD GRAM POSITIVE COVERAGE ( AKA VANCOMYCIN)IDSA Guidelines: Neutropenic Fever

Q7b:Inyourseconddream,despiteIVCefepime andIVVancomycinfor7

days,Mdm Ang continuedtospiketemperature.Hercountsremainedlowon

dailygcsf.Whatelsewouldyoudo?(choose1)

EscalateantibioticstoMeropenem

ChangeVancomycintoDaptomycin

ChangeIVCefepime toIVTazocin

AddIVCaspofungin

StartIbruprofen

Q7b:Inyourseconddream,despiteIVCefepime andIVVancomycinfor7

days,Mdm Ang continuedtospiketemperature.Hercountsremainedlowon

dailygcsf.Whatelsewouldyoudo?(choose1)

EscalateantibioticstoMeropenem

ChangeVancomycintoDaptomycin

ChangeIVCefepime toIVTazocin

AddIVCaspofungin

StartIbruprofen

IDSA Guidelines: Neutropenic Fever

Q7c:Inyourlastdream,beforeyouwokefromallyournightmares,Mdm Ang was

notedtohaveacatheter-relatedlineinfection.Whicharethemicroorganisms,if

growingfromtheline,doNOTrequireyoutoremovetheline?(Choose1)

Staphylococcusaureus

Pseudomonasaeruginosa

Candida

Staphylococcushaemolyticus

Mycobacteria

Q7c:Inyourlastdream,beforeyouwokefromallyournightmares,Mdm Ang was

notedtohaveacatheter-relatedlineinfection.Whicharethemicroorganisms,if

growingfromtheline,doNOTrequireyoutoremovetheline?(Choose1)

Staphylococcusaureus

Pseudomonasaeruginosa

Candida

Staphylococcushaemolyticus

Mycobacteria

Recommendation■ Differentialtimetopositivity(DTP)>120minofqualitativebloodculturesperformedonspecimens

simultaneouslydrawnfromtheCVCandaveinsuggestsacentralline–associatedbloodstreaminfection(CLABSI)(A-II).

■ ForCLABSIcausedbyS.aureus,P.aeruginosa,fungi,ormycobacteria,catheterremovalisrecommendedinadditiontosystemicantimicrobialtherapyforatleast14days(A-II).Catheterremovalisalsorecommendedfortunnelinfectionorportpocketsiteinfection,septicthrombosis,endocarditis,sepsiswithhemodynamicinstability,orbloodstreaminfectionthatpersistsdespite>72hoftherapywithappropriateantibiotics(A-II).

■ FordocumentedCLABSIcausedbycoagulase-negativestaphylococci,thecathetermayberetainedusingsystemictherapywithorwithoutantibioticlocktherapy(B-III).

■ Prolongedtreatment(4–6weeks)isrecommendedforcomplicatedCLABSI,definedasthepresenceofdeeptissueinfection,endocarditis,septicthrombosis(A-II)orpersistentbacteremiaorfungemiaoccurring>72haftercatheterremovalinapatientwhohasreceivedappropriateantimicrobials(A-IIforS.aureus,C-IIIforotherpathogens).

IDSA Guidelines: CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION

LEARNING POINTSSKILLS

1. Evidence-basedmedicine:touseyourclinicalreasonining andunderstandofevidence

2. Synthesisofinformationandgeneratingalistofproblems

3. Approachtoclinicalquestions

CONTENT

1. NeutropenicSepsis

2. INFECTIONSINANIMMUNOCOMPROMISEDHOST

THANK YOUAny Questions?

Evelyn Wong

MDM ANG B - Nigel Fong€¦ · · 2017-09-10MDM ANG B.C Evelyn Wong ... , IE not R/O), Undrained abscesses, Indwelling prosthesis ... You are now the clerking HO and

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