Thread by @mghmedres

1/ 34 y/o F with new AML dx on chemo (7+3) ANC 200. Counts are expected to continue to drop & not get better for at least another ~10d. Has been febrile 🌡️🔥 & on cefepime 2g q8 for the past 5 days💊💉. What do you do next?

#MedTwitter #OncTwitter #IDTwitter

2/ Former chief resident & leukemia doc @andrewbrunner from @MGHCancerCenter spoke about acute leukemias & #FebrileNeutropenia (F+N) ! Here are some #ConferenceTwearls

Definition:

Febrile: ≥ T 100.4 🌡️

➕

Neutropenia: ANC ≤ 500 or an expected 📉 to an ANC of ≤ 500 in 48h

3/ It's 🔑to look for a source of possible infection. BCx for all comers! Additional w/u depends on the clinical context.

📸Low threshold to image/scope these pts since they may not present classically---> e.g. pt w perforated abdomen can present w soft abdomen on PE.

4/ Start empiric abx ASAP while you await cultures with agents that target gram negatives ... including Pseudomonas!!

e.g. cefepime, piperacillin-tazobactam, ceftazidime 💊

Yep...Heme Onc shares the same feelings about 👑🍇 Pseudomonas as @DGlaucomflecken

5/ 🗓️With prolonged febrile neutropenia (>4-7 days), make sure that you thoroughly explored sources of infection --->

If there is no clear source of infxn & you don't expect count recovery soon in ~7d-> consider antifungals as the next step🍄

✅ANS to our case: MICAFUNGIN

6/ So when should you start vancomycin?

ONLY IF:
😷 if hemodynamically unstable

or

🦠high risk of g+ infection situations as noted in the image:

7/ Here is a graphic summary by SAR @HawraAllawati derived from the MGH F+N pathway by @mgh_ast @ARLetourneau