Systematic Approach to Causes of Fever and Infection in the High-Risk Hematology Patient Without an Obvious Source - Flowchart
Systematic Approach to Causes of Fever and Infection in the High-Risk Hematology Patient Without an Obvious Source - Flowchart Fever and Infection in High-Risk Hematology Patient Without Obvious Source Fever and Infection in High-Risk Hematology Patient Without Obvious Source
«Flowchart»

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Start

Start

Step 1. Is the patient receiving gram-negative prophylaxis?

Step 1. Is the patient receiving gram-negative prophylaxis?

Step 1

Step 2. If the patient is HSV-seropositive or can give a clinical history of prior cold sores inside or outside the mouth, is the patient receiving antiviral prophylaxis?

Step 2. If the patient is HSV-seropositive or can give a clinical history of prior cold sores inside or outside the mouth, is the patient receiving antiviral prophylaxis?

Step 2

Step 3. Is the patient receiving prophylaxis directed toward Streptococcus viridans with penicillin or cefazolin?

Step 3. Is the patient receiving prophylaxis directed toward Streptococcus viridans with penicillin or cefazolin?

Streptococcus viridans Step 3

Step 4. Is the patient's catheter exit site or skin tunnel erythematous?

Step 4. Is the patient's catheter exit site or skin tunnel erythematous?

Step 4

Step 5. Is the patient receiving yeast prophylaxis?

Step 5. Is the patient receiving yeast prophylaxis?

Step 5

Step 6. Is the patient receiving mold prophylaxis, pharmacologic and environmental?

Step 6. Is the patient receiving mold prophylaxis, pharmacologic and environmental?

Step 6

Step 7. Is anaerobic coverage warranted due to soft tissue swelling in the neck or abdominal symptoms to suggest typhlitis?

Step 7. Is anaerobic coverage warranted due to soft tissue swelling in the neck or abdominal symptoms to suggest typhlitis?

Step 7

Step 8. If it is respiratory virus season, does the patient have respiratory virus symptoms or has had visitors with them?

Step 8. If it is respiratory virus season, does the patient have respiratory virus symptoms or has had visitors with them?

Step 8

Step 9. Is there neutropenia during the epidemiologic risk period for CMV reactivation?

Step 9. Is there neutropenia during the epidemiologic risk period for CMV reactivation?

Step 9

Step 10. Is hemorrhagic cystitis present?

Step 10. Is hemorrhagic cystitis present?

Step 10

Step 11. Are any epidemiologic risk factors present to suggest tuberculosis risk?

Step 11. Are any epidemiologic risk factors present to suggest tuberculosis risk?

Step 11

Add

Add

Add

Change or augment prophylaxis

Change or augment prophylaxis

Change or augment prophylaxis

End

End

End

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Add

Add

Add

Is mucositis particularly severe suggesting antiviral resistance?

Is mucositis particularly severe suggesting antiviral resistance?

Is mucositis particularly severe suggesting antiviral resistance?

Yes

Yes

Yes

No

No

No

Septic signs suggesting antibacterial resistance?

Septic signs suggesting antibacterial resistance?

Septic signs suggesting antibacterial resistance?

Add

Add

Add

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Initiate vancomycin treatment while awaiting culture results. If the patient is known to be colonized with vancomycin-resistant enterococcus, weigh the risks/benefits of linezolid treatment in place of vancomycin. If clinical improvement is not noted with initial therapy, consider adjunctive surgery for diagnosis and treatment.

Initiate vancomycin treatment while awaiting culture results. If the patient is known to be colonized with vancomycin-resistant enterococcus, weigh the risks/benefits of linezolid treatment in place of vancomycin. If clinical improvement is not noted with initial therapy, consider adjunctive surgery for diagnosis and treatment.

Initiate vancomycin treatment while awaiting culture results. If the patient is known to be colonized with vancomycin-resistant enterococcus, weigh the risks/benefits of linezolid treatment in place of vancomycin. If clinical improvement is not noted with initial therapy, consider adjunctive surgery for diagnosis and treatment.

Consider adding vancomycin × 2 days while awaiting blood culture results

Consider adding vancomycin × 2 days while awaiting blood culture results

Consider adding vancomycin × 2 days while awaiting blood culture results

Yes

Yes

Yes

No

No

No

If the fever persists over 3 to 7 days, a yeast organism may be resistant to the prophylaxis chosen (e.g., Candida krusei and Candida glabrata are resistant to fluconazole). Change from a prophylaxis mindset to an empirical treatment mindset. Evidence-based options include amphotericin products and voriconazole.

If the fever persists over 3 to 7 days, a yeast organism may be resistant to the prophylaxis chosen (e.g., Candida krusei and Candida glabrata are resistant to fluconazole). Change from a prophylaxis mindset to an empirical treatment mindset. Evidence-based options include amphotericin products and voriconazole.

If the fever persists over 3 to 7 days, a yeast organism may be resistant to the prophylaxis chosen (e.g., Candida krusei and Candida glabrata are resistant to fluconazole). Change from a prophylaxis mindset to an empirical treatment mindset. Evidence-based options include amphotericin products and voriconazole.

Candida krusei Candida glabrata

Add

Add

Add

Yes

Yes

Yes

No

No

No

Add if the patient has been or will be neutropenic for at least 21 days

Add if the patient has been or will be neutropenic for at least 21 days

Add if the patient has been or will be neutropenic for at least 21 days

Add

Add

Add

Review respiratory virus workup: Nasopharyngeal swabs for rapid antigen tests and cultures.

Review respiratory virus workup: Nasopharyngeal swabs for rapid antigen tests and cultures.

Review respiratory virus workup: Nasopharyngeal swabs for rapid antigen tests and cultures.

Diagnostic methods for CMV reactivation based on circulating white blood cells, such as the pp65 antigenemia test, may give false-negative results. Consider a DNA-based test such as PCR.

Diagnostic methods for CMV reactivation based on circulating white blood cells, such as the pp65 antigenemia test, may give false-negative results. Consider a DNA-based test such as PCR.

Diagnostic methods for CMV reactivation based on circulating white blood cells, such as the pp65 antigenemia test, may give false-negative results. Consider a DNA-based test such as PCR.

Send a viral urine culture and a urine BK virus PCR.

Send a viral urine culture and a urine BK virus PCR.

Send a viral urine culture and a urine BK virus PCR.

Pursue initially with chest radiography ± Mantoux test.

Pursue initially with chest radiography ± Mantoux test.

Pursue initially with chest radiography ± Mantoux test.