ABDOMINAL PAIN IN AN ONCOLOGY OR BONE MARROW TRANSPLANT (BMT) PATIENT (AKA TYPHLITIS)

Transcription

1 ABDOMINAL PAIN IN AN ONCOLOGY OR BONE MARROW TRANSPLANT (BMT) PATIENT (AKA TYPHLITIS) ALGORITHM. Abdminal Pain in an Onclgy r BMT Patient Page 1 f 8

2 OVERVIEW Typhlitis, als referred t as neutrpenic enterclitis, is an acute life-threatening cnditin, seen mst cmmnly in children with myelsuppressin. Mrtality and mrbidity rates assciated with typhlitis are very high and early diagnsis and treatment is imperative as the clinical curse prgresses very quickly. CLINICAL PRESENTATION A high index f suspicin fr typhlitis shuld be given t nclgy r BMT patients presenting with abdminal pain plus ne r mre f the fllwing: Fever (101 F/38.4 C r greater) Diarrhea and/r bldy stl Neutrpenia (abslute neutrphil cunt less than 500/mm 3 ) Inductin therapy r delayed intensificatin therapy fr acute lymphblastic leukemia 1 (ALL), infant ALL, diagnsis f acute myelid leukemia 1 (AML), r high-risk neurblastma 1 LABORATORY RADIOLOGIC STUDIES Currently there is n gld standard fr diagnsing typhlitis Labratry studies shuld include: Cmplete bld cell cunt (CBC) Cmprehensive metablic panel Serum lipase Serum amylase Bld cultures Stl cultures and Clstridium difficile txin shuld be cnsidered if clinically indicated Imaging: Cntrversy exists regarding the ideal mdality fr diagnstic imaging in patients with ptential typhlitis. The argument has been made that plain radigraphs are nnspecific. Hwever, abdminal x-rays alng with cnsideratin f clinical signs are sensitive enugh fr the diagnsis f typhlitis. TREATMENT THERAPEUTICS Treatment must be individualized t each patient Cnservative treatment cnsists f: Bwel rest with r withut nasgastric suctin Parenteral nutritin may be cnsidered Hemdynamic supprt Intravenus fluids, bld and platelets as needed Pharmactherapy RISK OF RECURRENCE Patients with a histry f typhlitis are at risk fr develping it again during subsequent treatment. Chemtherapy shuld be withheld until the patient has fully recvered and has healed cmpletely. Page 2 f 8

3 TABLE OF CONTENTS Algrithm Overview Target Ppulatin Clinical Management Initial Evaluatin- See Clinical Presentatin Labratry Studies Imaging Treatment Therapeutics References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria All nclgy and bne marrw transplant (BMT) patients with abdminal pain Exclusin Criteria General medicine patients Hematlgy patients CLINICAL MANAGEMENT Overview Typhlitis, als referred t as neutrpenic enterclitis 1, is an acute life-threatening cnditin, seen mst cmmnly in children with myelsuppressin. Mrtality and mrbidity rates assciated with typhlitis are very high and early diagnsis and treatment is imperative as the clinical curse prgresses very quickly 1. Telephne Triage Use the EPIC telephne triage script named HOB Typhlitis. Dcument the dispsitin f the patient in the field prvided. Clinical Presentatin A high index f suspicin fr typhlitis shuld be given t nclgy r BMT patients presenting with abdminal pain 2 plus ne r mre f the fllwing: Fever 1-3 (101 F/38.4 C r greater) Diarrhea 2,3 and/r bldy stl Neutrpenia 1-3 (abslute neutrphil cunt less than 500/mm 3 ) Inductin therapy r delayed intensificatin therapy fr acute lymphblastic leukemia 1 (ALL), infant ALL, diagnsis f acute myelid leukemia 1 (AML), r high-risk neurblastma 1 Differential Diagnses Signs and symptms f typhlitis ften mimic ther cmmn gastrintestinal disrders including appendicitis, clnic pseud-bstructin, diverticulitis, inflammatry bwel disease, infectius clitis, pancreatitis, and pseudmembranus clitis 3. Page 3 f 8

4 LABORATORY RADIOLOGIC STUDIES Currently there is n gld standard fr diagnsing typhlitis Labratry studies shuld include: Cmplete bld cell cunt (CBC) 4 Cmprehensive metablic panel 4 Serum lipase Serum amylase Bld cultures 4 Stl cultures and Clstridium difficile txin 5 shuld be cnsidered if clinically indicated Imaging: Cntrversy exists regarding the ideal mdality fr diagnstic imaging in patients with ptential typhlitis. The argument has been made that plain radigraphs are nnspecific. Hwever, abdminal x-rays alng with cnsideratin f clinical signs are sensitive enugh fr the diagnsis f typhlitis 4. Radigraphic findings suggestive f typhlitis include: Thumb printing Fluid-filled mass like density in the right lwer quadrant f the abdmen Lcalized pneumatsis Distentin f adjacent bwel lps CT scans can als be used fr diagnsis. In cases where ther pathlgy is a cncern, this may be indicated, but abdminal x-ray has been shwn t be a very sensitive test fr the diagnsis f typhlitis. TREATMENT THERAPEUTICS Treatment must be individualized t each patient 4. Cnservative treatment cnsists f: Bwel rest 3 with r withut nasgastric suctin Parenteral nutritin may be cnsidered Hemdynamic supprt Pharmactherapy 3 Intravenus fluids, bld and platelets as needed Cefepime: 50 mg/kg/dse intravenusly every 8 hrs. Maximum: 6 grams/day plus metrnidazole: 7.5 mg/kg/dse intravenusly every 6 hrs r 10 mg/kg/dse intravenusly every 8 hrs. Recmmended maximum: 2 grams/day Cnsider additinal Gram-negative cverage in patients wh are clinically unstable, when resistant infectin is suspected 6,7 The agent t select fr duble cverage is cntrversial, as aminglycsides are f variable benefit and increased nephrtxicity, and flurquinlnes increase risk f C. difficile disease 6,8 Discntinue duble Gram-negative cverage in patients wh are clinically respnding after 48 t 72 hurs, if there is n specific micrbilgic clinical indicatin t cntinue 6 Cnsider adding entercccal cverage per patient risk factrs and clinical severity, per Natinal Fever and Neutrpenia guidelines 6 Page 4 f 8

5 Cnsider expanding/adding anti-fungal cverage per patient risk factrs and clinical severity, per Natinal Fever and Neutrpenia guidelines 6 Fr patients with cephalsprin allergy, chices include merpenem 20 mg/kg/dse intravenusly every 8 hrs (single agent) Maximum: 3 grams/day, r ciprflxacin 10 mg/kg/dse intravenusly every 12 hurs (Recmmended maximum: 800 mg/day) + metrnidazole 7.5 mg/kg/dse intravenusly every 6 hrs r 10 mg/kg/dse rally r intravenusly every 8 hrs (Recmmended maximum: 2 grams/day) If merpenem used, there is n clear benefit t duble gram negative cverage, thugh exceptin made fr patients already n merpenem (fr example fr BMT prphylaxis) 8 Duble anaerbic cverage shuld be avided, as it is unnecessary and may increase risk f disease with C. difficile. Agents with significant anaerbic cverage used in this ppulatin include merpenem, piperacillin/tazbactam, ticarcillin/clavulanic acid, metrnidazle, and clindamycin (nte: clindamycin is less effective against B. fragilis) 9 D NOT administer antichlinergics r antidiarrheals, as they may aggravate the cnditin r cmplicate the clinical presentatin. Cnsider surgical cnsultatin Immediate surgery is indicated fr patients with free intra-abdminal perfratin, clinical deteriratin during cnservative medical treatment, unrelenting intra-abdminal sepsis r abscess frmatin, r cntinued hemrrhage 10. Risk f Recurrence Patients with a histry f typhlitis are at risk fr develping it again during subsequent treatment. Chemtherapy shuld be withheld until the patient has fully recvered and has healed cmpletely. Page 5 f 8

6 References 1. Mullassery D, Bader A, Battersby AJ, et al. Diagnsis, incidence, and utcmes f suspected typhlitis in nclgy patients--experience in a tertiary pediatric surgical center in the United Kingdm. J Pediatr Surg 2009;44: Shafey A, Ethier MC, Traubici J, Naqvi A, Sung L. Incidence, risk factrs, and utcmes f enteritis, typhlitis, and clitis in children with acute leukemia. J Pediatr Hematl Oncl 2013;35: Clutier RL. Neutrpenic enterclitis. Emerg Med Clin Nrth Am 2009;27: Mran H, Yaniv I, Ashkenazi S, Schwartz M, Fisher S, Levy I. Risk factrs fr typhlitis in pediatric patients with cancer. J Pediatr Hematl Oncl 2009;31: El-Matary W, Sleimani M, Spady D, Belletrutti M. Typhlitis in children with malignancy: a single center experience. J Pediatr Hematl Oncl 2011;33:e Lehrnbecher T, Phillips R, Alexander S, et al. Guideline fr the management f fever and neutrpenia in children with cancer and/r underging hematpietic stem-cell transplantatin. J Clin Oncl 2012;30: Freifeld AG, Bw EJ, Sepkwitz KA, et al. Clinical practice guideline fr the use f antimicrbial agents in neutrpenic patients with cancer: 2010 update by the infectius diseases sciety f america. Clin Infect Dis 2011;52:e Sick AC, Tschudin-Sutter S, Turnbull AE, Weissman SJ, Tamma PD. Empiric Cmbinatin Therapy fr Gram- Negative Bacteremia. Pediatrics Snydman DR, Jacbus NV, McDermtt LA, et al. Lessns learned frm the anaerbe survey: histrical perspective and review f the mst recent data ( ). Clin Infect Dis 2010;50 Suppl 1:S Chui CH. Surgical management f cmplicatins f multimdal therapy. Pediatr Bld Cancer 2012;59: Page 6 f 8

7 CLINICAL IMPROVEMENT TEAM MEMBERS Janne Hilden, MD Hematlgy/Onclgy Timthy Garringtn, MD Hematlgy/Onclgy Amanda Hurst, PharmD Clinical Pharmacist Aimee Bernard, PhD Clinical Care Guideline Crdinatr APPROVED BY Clinical Care Guidelines & Measures Review Cmmittee December 2014 Antimicrbial Stewardship Cmmittee December 2014 and March 2016 Pharmacy & Therapeutics Cmmittee December 2014 MANUAL/DEPARTMENT Clinical Care Guidelines/Quality ORIGINATION DATE March 1, 2011 LAST DATE OF REVIEW OR REVISION March 1, 2016 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW/REVISION SCHEDULE Scheduled fr full review n March 1, 2020 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 7 f 8

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