Clinical Index of Stable Febrile Neutropenia (CISNE)

Why Use

More specific than the MASCC Risk Index .

When to Use

Adult outpatients ≥18 years old with solid tumor, fever ≥38°C (100.4°F) over 1 hour, and neutropenia (500 cells/mm³or fewer, or 1,000 cells/mm³ with expected decrease to 500). Should not be used in patients who are obviously unwell, defined by the original study authors as any of the following: Acute organ failure (renal, cardiac, and respiratory). Decompensation of chronic organ insufficiency. Septic shock and hypotension (systolic BP <90 mmHg). Known severe infection. Other serious complications that would themselves require admission.

Formula

Pearls / Pitfalls

While only solid tumors were included in the original study, an external validation study including both solid and hematologic malignancies showed no significant difference in outcomes for low-risk patients with either type. Complications included hypotension, acute organ failure, arrhythmia, major bleeding, delirium, acute abdomen, DIC , and “other events considered severe” (see Facts & Figures for full definitions). Uses mostly objective variables.

Management

As with all prediction tools, use clinical judgment and err on the side of caution when scores are equivocal.

Advice

Higher scores indicate higher risk for complications.

More Information

Interpretation: CISNE Risk category Risk of complications* Recommendation 0 I (Low) 1.1% Consider discharge with oral antibiotics after discussion with oncology. 1-2 II (Intermediate) 6.2% Use clinical judgment regarding admission. Consider oncology consultation. ≥3 III (High) 36% Admit for further investigation, including blood cultures. *Any of the following complications within 7 days minumum, from ED arrival until complete resolution of the episode, defined as "disappearance of all signs of infection with recovery from neutropenia (≥1,500 neutrophils/μL) and absence of fever for 48 hours, including home surveillance if patient was discharged early": Hypotension: persistent systolic blood pressure <90 mmHg requiring inotropes or aggressive fluid resuscitation. Acute respiratory failure: SaO 2 <90%, PaO 2 <60 mmHg, or PaCO 2 ≥45 mmHg. Acute renal failure: increase in creatinine >0.3 mg/dL within 48 hours, increase in creatinine to ≥1.5× baseline within prior 7 days, or urine volume <0.5 mL/kg per hour for 6 hours. Acute heart failure: rapid onset of dyspnea, pulmonary edema, and oxygen desaturation requiring urgent therapy. Arrhythmia: any that alter cardiovascular stability. Major bleeding: episodes associated with death, occurring in critical localization (intracranial, intraspinal, intraocular, retroperitoneal, or pericardial), or associated with reduction in hemoglobin values ≥2 g/dL or bleeding requiring transfusion of two units RBCs. Delirium: acute, fluctuating alteration of mental state with cognitive impairment. Acute abdomen: requiring urgent medical or surgical management. Disseminated intravascular coagulation.