Professional Documents
Culture Documents
Christian Manginstar
CNS
Cardiologic
Gastrointestina
l
Sympthomatic
Emergencies
Oncologic Hematologic
Emergencies
Emergency
Intervensi
Respiratory
Emergencie Segera Infection
Emergencies
Neutropenia
Infectio
n
Febrile Sepsis
s
Clinical outcomes :
Neutropenia induce Prolonged hospital stay
Chemotherapy solid
tumor
Increased diagnostic
and treatment costs
25- 40%.
Delayed chemotherapy
Chemotherapy dose
Neutropenia solid tumor : reductions
breast (27%), lung Quality of Life
(16%), ovarian (13%) Increased mortality
and esophageal (13%)
cancers.
Absence of Granulocytes
Increase Infection
Disruption of
Integumentary,
mucosal and
muco-ciliary
barriers
Shifts of inherent
microbial flora
Etiology & Epidemiology
FN : 10-50% during
Chemoth Solid tumor ( >
80% HM)
Infection in 20-30%
Febrile episodes.
Tahun terakhir: > Gr (+)
Drug-resistant gr(-) >>
Infection patients FN
Definisi:
Singel oral temp > 38.3oC
(101oF) OR
Repeated oral temps > 38.0oC
(100.4oF) utk 1 jam
NCCN 2013
Assesment Awal (Triage)
Neutropenia : PS :
Chemoth. Patients with Tempperatur, pulse,
fever (38oC) RR, BP, SaO2, GCS
Patients 3 months or <
after bone marrow
Sepsis/ syok
transplant resusitasi
Pemeriksaan dan Anamnesa
Sec. Survey :
Chest
Anamnesa:
Mucous membranes
Type of cancer,
Skin
Chemotherapy,
Venous access
steroid, antibiotic,
Peri-anal area surgical procedure,
Urinary tract allergies
Gastrointestinal tract ( Mengenal Faktor
resiko)
Cat : sign of infection (-)
little or no inflamatory
respoons, or syok/ MODS
Faktor Resiko
Langkah Umum :
Cuci tangan
Menjaga kebersihan kulit keseluruhan
( preventing Staph. aureues ).
Menghindari genangan air (Parasit)
Menghindari makanan dengan
kandungan bakteri tinggi
Kebersihan mulut
PROPHYLAXIS :
MYELOID GROWTH FACTORS
types
1. Granulocyte Colony Stimulating Factors (GCSF)
2. Granulocyte Macrophage Colony Stimulating
Factors (GM- CSF)
Penggunaan :
Profilaksis : Primer, Sekunder
Terapi
Granulocyte Colony Stimulating Factor (G-CSF)
G-CSF : stimulasi proliferasi, diferensiasi, maturasi sel
progenitor neutrofil, stimulasi neuPD, : waktu transit
me aktivitas neu.
Filgrastim : do : 5 gr/kgBB
Pegfilgasrim : singel dose 6g/cycle
Granulocyte Macrophage Colony
Stimulating Factors (GM- CSF)
Sargramostin :
1. Induction in AML
2. Stem cell transplant
Waktu pemberian ?
Patient factor
Chemotherapy
1. High dose
2. Dose dense
3. Standard Dose
Curative vs Palliative
Keganansan yang
mendasari
Penyakit yang
mendasari
Lamanya neutropenia
Profilaksis
Chemotherapy
antibiotik
Intensitas terapi
imunosupresi
Prophylactic antibiotics :
Fluoroquinolone
Cat. :
1. Prophylaxis tidak terkait penurunan
bacteremia.
2. Resistan Quinolone
Imipenem-cilastin (Carbapenem)
Broad spectrum gram(-), gram(+) & anaerobic and
ESBL coverage
Use for intra-abdominal source
Risk of seizures in CNS malignancy or renal
impairment
Meropenem
Broad spectrum gram(-), gram(+) &
anaerobic
Use for intra-abdominal source
Preferred for meningitis/CNS infection
Dosing:
150 mg PO daily x 14 dose for vaginal candidiasis
200 mg PO daily x14 days for candidal
pyelonephritis
400 mg PO daily prophylaxis for neutropenic
patients
NCCN Recommends :
Ganciclovir:
CMV treatment: 5 mg/kg IV Q12h x2 weeks then 5
mg/kg IV Q24h x2-4 weeks
Foscarnet:
Acyclovir-resistant HSV: 40 mg/kg IV Q8h
CMV treatment: 90 mg/kg IV Q12h x2 weeks then 120
mg/kg IV Q24h x2-4 weeks
Oseltamivir:
Influenza: 75 mg PO Q12h
(reduced doses required in renal impairment)
CNS
CT +/- MRI
LP recommended
Empiric therapy:
Anti-pseudomonal CSF (ceftazidime, meropenem)
Vancomycin pilihan pertama, especially if neurosurgical.
Adjuvant dexamethasone
For suspected Abscess, tambahkan metronidazole.
Use cotrimoxazole, if suspect toxoplasma and nocardia
Pneumonia
Px. tambahan: Chest radiographs+ blood culture
Cultures : sputum
Nasal wash for respiratory virus
Legionella antigen test
BAL
anti-pseudomonal diberikan
atypical bacteria azithromycin/ fluroquinolones
MRSA vancomycin
Aspergilosis antifungal (voriconazole / amphotericin
B) if high risk
Gastrointestinal Symptoms
Abdominal pain
CT Abdominal
ALP, transaminases, bilirubin, amylase, lipase
anaerobic + anti-pseudomonal
Anti-fungal prophylaxis as candida.
Diarrhoea
cultures feses
C.difficile suspected, oral metronidazole +
nasogastric
INVASIVE CANDIDIASIS