Febre Neutropénica

Descrição Geral

Definição

A febre neutropénica é definida como uma temperatura oral única > 38,3 ℃ (100,4 ℉) ou uma temperatura > 38,0 ℃ (100,4 ℉) durante, pelo menos, 1 hora e, associadamente, uma contagem absoluta de neutrófilos (CAN) < 1500 células/µL ou uma CAN em que é expectável que diminua para < 500 células/µL durante as próximas 48 horas.

Epidemiologia

• A neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia febril desenvolve-se em:
  • 10%–50% dos doentes com tumores sólidos
  • 80% dos doentes com tumores hematológicos
• 50% dos doentes irão desenvolver uma infeção.
• A fonte da infeção é evidente em 20%–30% dos casos
• O exame objetivo/cultura não deteta o foco infeccioso/patogénio em 30%–60% dos casos.
• 80% das infeções ocorrem a partir da flora normalmente benigna ou comensal do paciente.
• Os locais mais MAIS Androgen Insensitivity Syndrome comuns de infeção incluem:
  • Pulmão
  • Pele
  • Sangue
  • Trato GI

Etiologia

Na maioria dos casos, a fonte da infeção é desconhecida (referida como febre de origem indeterminada (FOI)). A maioria das infeções documentadas são bacterianas.

As fontes mais MAIS Androgen Insensitivity Syndrome comuns de bacteremia Bacteremia The presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion. Glycopeptides são:

• Translocação de bactérias entéricas para a corrente sanguínea
• Infeções da corrente sanguínea associadas ao cateter

Bactérias patogénicas mais MAIS Androgen Insensitivity Syndrome comuns:

• Gram-positivos (correspondem a mais MAIS Androgen Insensitivity Syndrome de ½ dos casos):
  • Estafilococos coagulase-negativos ( mais MAIS Androgen Insensitivity Syndrome comuns)
    • Staphylococcus epidermidis Staphylococcus epidermidis A species of staphylococcus that is a spherical, non-motile, gram-positive, chemoorganotrophic, facultative anaerobe. Mainly found on the skin and mucous membrane of warm-blooded animals, it can be primary pathogen or secondary invader. Staphylococcus
    • Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus haemolyticus
  • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess (incluindo o MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus)
  • Enterococos (incluindo os resistentes à vancomicina)
  • Estreptococos do grupo Viridans
  • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pyogenes
  • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pneumoniae
  • Espécies de Bacillus Bacillus Bacillus are aerobic, spore-forming, gram-positive bacilli. Two pathogenic species are Bacillus anthracis (B. anthracis) and B. cereus. Bacillus
• Gram-negativos:
  • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli
  • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas
  • Espécies de Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella
  • Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections
  • Fusobacterium Fusobacterium A genus of gram-negative, anaerobic, rod-shaped bacteria found in cavities of humans and other animals. No endospores are formed. Some species are pathogenic and occur in various purulent or gangrenous infections. Dog and Cat Bites
  • Espécies de Acinetobacter Acinetobacter Multidrug-resistant Organisms and Nosocomial Infections
  • Stenotrophomonas maltophilia

Fungos patogénicos mais MAIS Androgen Insensitivity Syndrome comuns:

• Espécies de Aspergillus Aspergillus A genus of mitosporic fungi containing about 100 species and eleven different teleomorphs in the family trichocomaceae. Echinocandins
• Espécies de Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis
• Espécies de Fusarium
• Fungos endémicos

Vírus patogénicos mais MAIS Androgen Insensitivity Syndrome comuns:

• Vírus herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections
• CMV
• Vírus influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza
• Vírus parainfluenza
• Adenovírus
• Vírus sincicial respiratório

Outros agentes patogénicos comuns:

• Strongyloides stercoralis Strongyloides stercoralis A species of parasitic nematode widely distributed in tropical and subtropical countries. The females and their larvae inhabit the mucosa of the intestinal tract, where they cause ulceration and diarrhea. Strongyloidiasis
• Espécies de Leishmania Leishmania Leishmania species are obligate intracellular parasites that are transmitted by an infected sandfly. The disease is endemic to Asia, the Middle East, Africa, the Mediterranean, and South and Central America. Clinical presentation varies, dependent on the pathogenicity of the species and the host’s immune response. Leishmania/Leishmaniasis
• Espécies de Trypanosoma

Fisiopatologia

A combinação dos seguintes fatores contribui para o desenvolvimento de febre neutropénica:

• Supressão da medula óssea induzida por quimioterapia
• Substituição metastática da medula óssea
• Produção/depuração anormal de anticorpos por neoplasias produtoras de anticorpos (por exemplo, mieloma múltiplo, leucemia linfocítica crónica), culminando numa asplenia Asplenia Asplenia is the absence of splenic tissue or function and can stem from several factors ranging from congenital to iatrogenic. There is a distinction between anatomic asplenia, which is due to the surgical removal of the spleen, and functional asplenia, which is due to a condition that leads to splenic atrophy, infarct, congestion, or infiltrative disease. Asplenia funcional
• Produção e função anormais das células T (linfoma)
• Lesão da mucosa induzida por quimioterapia
• Presença de possíveis fontes de infeção (cateteres invasivos)

Apresentação Clínica

A presença de neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia pode minimizar os sintomas e sinais da infeção:

• A ativação dos neutrófilos é responsável por muitos dos sintomas inflamatórios numa infeção
• Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia → ↓ ativação dos neutrófilos → ↓ libertação de citocinas → ↓ sintomas inflamatórios

A presença de febre pode ser o único sinal da presença de uma infeção.

Os sintomas mais MAIS Androgen Insensitivity Syndrome comuns da neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia febril são:

• Odinofagia
• Aftas orais
• Úlceras cutâneas
• Tosse
• Dispneia
• Disúria
• Polaquiúria e urgência miccional
• Rubor Rubor Inflammation e dor no local de inserção do cateter

Diagnóstico

Todos os doentes com neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia febril devem ser submetidos a uma história clínica e exame objetivo detalhados, bem como à realização de estudos diagnósticos.

História clínica

Uma história clínica detalhada deve incluir:

• Revisão de aparelhos e sistemas para localizar o foco da infeção
• Medicação atual
• Tipo de neoplasia
• Regime de quimioterapia atual
• Revisão de qualquer exame laboratorial recente, em especial de estudos hematológicos.
• Presença de alergias
• Utilização de corticoides
• Comorbilidades
• História prévia de infeções
• Profilaxia recente com antibióticos
• Administração recente de fatores de crescimento hematopoiéticos
• História prévia de transplante

Exame objetivo

Um exame objetivo completo deve incluir uma avaliação de:

• Pele:
  • Eritema
  • Dor
  • Úlceras
  • Abcessos
  • Locais de inserção de cateteres centrais
  • Ectima gangrenoso (ocorre na infeção por P. aeruginosa P. aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas)
• Fundo ótico: sinais de embolia séptica
• Seios perinasais
  • Dor
  • Aparência “húmida” (azulados, pálidos, edemaciados)
• Boca:
  • Úlceras
  • Doença periodontal
  • Leucoplasia
• Pulmões
• Abdómen:
  • Avaliação da mucosa visceral
  • Não realizar toque retal em doentes neutropénicos.
• Área perineal:
  • Quisto pilonidal
  • Abcesso perirretal
  • Infeção vaginal/vulvar
• Sistema neurológico:
  • Meningismo
  • Défice neurológico focal
  • Alteração do estado mental
• Locais de inserção do cateter:
  • Eritema
  • Flutuação
  • Dor
  • Palpação de um cordão ao longo do trajeto da veia

Exames complementares de diagnóstico

Avaliação laboratorial:

• Hemograma com contagem diferencial de leucócitos:
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia grave: CAN < 500 células/µL
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia profunda: CAN < 100 células/µL
• Tipagem sanguínea
• Estudos da coagulação
• Parâmetros bioquímicos:
  • Função renal
  • Função hepática
  • Eletrólitos
• Lactatos: Níveis elevados são sugestivos de sépsis.
• Análise sumária de urina
• PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR)
• VS
• Procalcitonina (PCT):
  • Pró-hormona da calcitonina, produzida na presença de uma infeção sistémica em resposta às toxinas microbianas e aos mediadores inflamatórios do hospedeiro
  • Pode ajudar a diferenciar as etiologias infeciosas e não infeciosas de febre:
    • Elevada nas infeções bacterianas
    • Elevada nas infeções fúngicas
  • Pode ajudar na seleção e duração do tratamento com antibióticos:
    • Quando elevada, reforça a importância de iniciar um antibiótico
    • Quando não está elevada, reforça a decisão de suspender ou protelar o início da antibioterapia
  • Ajuda na prevenção de uma terapêutica com antibiótico prolongada/desnecessária

Cultura:

• Hemocultura:
  • Devem ser obtidos 2 sets de hemoculturas através da punção venosa periférica de 2 locais diferentes, bem como de qualquer cateter venoso invasivo.
  • 1 set é composto por 2 garrafas (aeróbia e anaeróbia).
• A urocultura deve ser obtida se:
  • Doente sintomático
  • Doente com história prévia de infeção do trato urinário
  • Presença de algaliação
• Cultura dirigida ao foco
  • Microscopia e cultura de fezes na presença de diarreia ( Clostridium difficile Clostridium difficile A common inhabitant of the colon flora in human infants and sometimes in adults. The type species clostridioides difficile is formerly known as Clostridium difficile. It is a causative agent for clostridioides infections and is associated with pseudomembranous enterocolitis in patients receiving antibiotic therapy. Clostridia)
  • Microscopia e cultura da expetoração na presença de sinais de infeção respiratória
  • Zaragatoa cutânea/lesão

Imagiologia:

• Deve obter-se uma radiografia do tórax ou tomografia computadorizada.
• Quando clinicamente indicado, devem ser realizados estudos imagiológicos adicionais.

Tratamento

Abordagem geral

• Considerações para avaliação de risco:
  • Score da Multinational Association for Supportive Care in Cancer (MASCC)
  • Adequação do doente para um tratamento ambulatório versus hospitalar
  • Adequação do doente para antibioterapia oral versus IV
  • Duração prevista do tratamento
  • Disponibilidade do cuidador
• Doentes de baixo risco:
  • Duração da neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia ≤ 7 dias
  • Sem comorbilidades
  • Funções hepática e renal normais
  • Pontuação MASCC ≥ 21
• Doentes de alto risco:
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia profunda (CAN ≤ 100 células/µL)
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia prolongada (≥ 7 dias)
  • A realizar profilaxia com uma fluoroquinolona
  • Pontuação MASCC < 21
  • Patologias comórbidas:
    • Dor abdominal de novo
    • Hipotensão
    • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Alterações neurológicas
    • Evidência laboratorial de disfunção orgânica
    • Instabilidade hemodinâmica
• O tratamento empírico deve ser iniciado na 1ª hora após a admissão.
• Seleção dos antibióticos empíricos:
  • Ajustados à fonte de infeção conhecida/suspeita
  • Em doentes que já estão a realizar um tratamento profilático com uma fluoroquinolona, deve ser dado um antibiótico beta-lactâmico antipseudomónico
  • Se a fonte da infeção é desconhecida:
    • Cobertura de largo espectro
    • Considerar a avaliação por um especialista em doenças infecciosas.

Doentes de baixo risco

Os doentes de baixo risco são tratados no ambulatório ou inicialmente em regime de internamento e, a seguir, são transferidos para o ambulatório com acompanhamento frequente (antibioterapia oral).

• Ausência de alergia à penicilina: levofloxacina/ciprofloxacina mais MAIS Androgen Insensitivity Syndrome amoxicilina-clavulanato
• Alergia à penicilina: clindamicina mais MAIS Androgen Insensitivity Syndrome levofloxacina/ciprofloxacina
• Outros: moxifloxacina em monoterapia
• Inicialmente, não está recomendado nenhum tratamento antifúngico.
• Quando a febre persiste por ≥ 4-7 dias, devem ser administrados antifúngicos de largo espectro.

Doentes de alto risco

Os doentes de alto risco devem ser tratados em regime de internamento (antibioterapia IV).

• Ausência de alergia à penicilina:
  • Piperacilina– tazobactam Tazobactam A penicillanic acid and sulfone derivative and potent beta-lactamase inhibitor that enhances the activity of other anti-bacterial agents against beta-lactamase producing bacteria. Cephalosporins
  • Meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam
  • Imipenem Imipenem Semisynthetic thienamycin that has a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to beta-lactamases. Clinical studies have demonstrated high efficacy in the treatment of infections of various body systems. Its effectiveness is enhanced when it is administered in combination with cilastatin, a renal dipeptidase inhibitor. Carbapenems and Aztreonam–cilastatina
  • Cefepime Cefepime A fourth-generation cephalosporin antibacterial agent that is used in the treatment of infections, including those of the abdomen, urinary tract, respiratory tract, and skin. It is effective against pseudomonas aeruginosa and may also be used in the empiric treatment of febrile neutropenia. Cephalosporins
• Caso complicado ou resistência a antibióticos: Deve adicionar-se um aminoglicosídeo aos regimes acima.
  • Gentamicina
  • Amicacina
  • Tobramicina
• Alergia à penicilina:
  • Ausência de profilaxia com uma fluoroquinolona: ciprofloxacina mais MAIS Androgen Insensitivity Syndrome clindamicina
  • Sob profilaxia com uma fluoroquinolona: aztreonam Aztreonam The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam mais MAIS Androgen Insensitivity Syndrome vancomicina
• Doentes com enterocolite neutropénica:
  • Piperacilina – tazobactam Tazobactam A penicillanic acid and sulfone derivative and potent beta-lactamase inhibitor that enhances the activity of other anti-bacterial agents against beta-lactamase producing bacteria. Cephalosporins
  • Carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam
  • Cefalosporina antipseudomónica mais MAIS Androgen Insensitivity Syndrome metronidazol
• Organismos resistentes à antibioterapia:
  • S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus resistente à meticilina:
    • Daptomicina
    • Linezolida
    • Vancomicina
  • Enterococos resistentes à vancomicina (VRE, pela sigla em inglês):
    • Daptomicina
    • Linezolida
  • ESBL ESBL Klebsiella:
    • Carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam
  • Carbapenemase de Klebsiella pneumoniae Klebsiella Pneumoniae Gram-negative, non-motile, capsulated, gas-producing rods found widely in nature and associated with urinary and respiratory infections in humans. Aminoglycosides (KPC, pela sigla em inglês):
    • Polimixina B
    • Colistina
    • Tigeciclina
• Indicações para a adição de vancomicina:
  • Instabilidade hemodinâmica
  • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Hemoculturas positivas para bactérias gram-positivas
  • Infeção da pele ou tecidos moles Moles Primary Skin Lesions
  • Infeção associada ao cateter
  • Colonização com MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus, Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus resistente à penicilina
• Tratamento antifúngico:
  • Indicações:
    • Doente instável e
    • A febre persiste ＞ 4–7 dias
  • Fármacos:
    • Anfotericina B (aspergilose invasiva)
    • Voriconazol (aspergilose invasiva)
    • Itraconazol
    • Posaconazol
    • Caspofungina (candidíase)
    • Micafungina
• Tratamento antivírico:
  • Indicações:
    • Doença vírica ativa por herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections/varicela zoster
    • Transplante de medula óssea recente/atual
  • Fármacos
    • Aciclovir para o herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections
    • Aciclovir para o varicela zoster
    • Inibidores da neuraminidase Neuraminidase An enzyme that catalyzes the hydrolysis of alpha-2, 3, alpha-2, 6-, and alpha-2, 8-glycosidic linkages (at a decreasing rate, respectively) of terminal sialic residues in oligosaccharides, glycoproteins, glycolipids, colominic acid, and synthetic substrate. Antivirals for Influenza na infeção suspeita/confirmada por influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza

Duração do tratamento

• Identificação da fonte de infeção:
  • Duração do tratamento ajustada consoante a infeção em específico e
  • CAN ≥ 500 células/µL
• Fonte de infeção desconhecida:
  • Febre resolvida ≥ 48 horas e
  • CAN ≥ 500 células/µL

Tratamento de suporte

• Fluidos IV
• Não está recomendada a administração do fator estimulador de colónias (CSF, pela sigla em inglês)
• Indicações para a remoção de cateteres invasivos:
  • Infeção do túnel ou da porta do cateter
  • Sépsis (se a fonte infecciosa for desconhecida)
  • Endocardite
  • Embolia séptica
  • Infeção que persiste há > 72 horas apesar da antibioterapia
  • Infeção causada por:
    • S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus
    • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus
    • Fungos
    • Micobactérias não tuberculosas

Profilaxia

• Indicações:
  • Doentes de alto risco
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia profunda
  • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia prolongada
• Fármacos:
  • Levofloxacina
  • Ciprofloxacina
  • Azóis
  • Trimetoprim-sulfametoxazol ( pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia por Pneumocystis jirovecii )

Diagnóstico Diferencial

• Reação transfusional: complicação associada a tratamentos transfusionais (podem ser de derivados ou do sangue completo). Esta reação apresenta-se com febre, arrepios, urticária, prurido, dispneia, hipotensão e dificuldade respiratória. O diagnóstico baseia-se no surgimento de sintomas durante ou após a transfusão. O tratamento inclui a interrupção da transfusão, administração de fluidos IV, anti-histamínicos e antipiréticos.
• Febre neoplásica: síndrome paraneoplásica causada por certas neoplasias (principalmente hematológicas). O único sintoma à apresentação é febre, sem sinais de infeção ou reação medicamentosa. A febre neoplásica é um diagnóstico de exclusão. A administração de naproxeno pode diminuir a temperatura. O tratamento inclui tratar a doença subjacente e o controlo dos sintomas com AINEs, paracetamol paracetamol Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen e corticoides.