13 Chemotherapy-Induced Neutropenia Lee

Question 1

What is the most common dose-limiting toxicity of chemotherapy?

Answer 1

Myelosuppression

Question 2

What is Nadir?

Answer 2

The time after chemotherapy at which number of blood cells in the periphery is the lowest

Question 3

What are the life-threatening consequences of Neutropenia?

Answer 3

Increased risk of infection. Prolonged hospitalization for administration of IV abx. Interruptions in cancer treatment. Increased mortality

Question 4

What are the patterns of chemotherapy-induced neutropenia?

Answer 4

Rapid: onset within 10-14 days, recover in 3-4 weeks. Delayed: 4-6 weeks, recovery in 6-8 weeks

Question 5

What is Febrile Neutropenia (FN)?

Answer 5

Absolute neutrophil count (ANC) < 500 cells/mm3 or < 1000 cell/mm3 with a predicted decline to < 500/mm3 within 48 hours. Single temp > 38.2 (101F) or > 37 (100.4) for > 1 hour

Question 6

What are the symptoms to monitor closely with Neutropenia?

Answer 6

Concerned with infection, watch for: Fever and shaking chills, Dizziness or fainting, Redness or swelling of skin or open wound, Respiratory symptoms (cough or sinus congestion)

Question 7

When is the risk for Febrile Neutropenia (FN) the greatest?

Answer 7

When ANC < 100 cell/mm3

Question 8

What are some common pathogens in FN patients?

Answer 8

Primarily bacterial. Gram (+): Staph aureus, Enterococci, Ciridans group streptococci. Gram (-): E. coli, Klebsiella, P. aeruginoa, Enterobacter. Anaerobes infrequent

Question 9

What are some prophylactic antimicrobials for FN?

Answer 9

Levofloxacin. TMP-SMX (at risk for Pneumocystis jiroveci). Fluconazole and Acyclovir

Question 10

What are Low Risk patients for getting infection?

Answer 10

Outpatients. No associated comorbid illness. Solid tumor patients. Serum Cr < 2. LFTs < 3x normal

Question 11

What are High Risk patients for getting infection?

Answer 11

In-patient. Associated comorbid illness that requires hospitalization. Uncontrolled/progressive cancer. Prolonged neutropenia (< 100 for > 7 days). Pneumonia. Advanced age. Stem cell recipients

Question 12

What does a score of 21 or higher indicate in the MASCC/IDSA scoring index?

Answer 12

Patient is likely to be at low risk for complications with FN

Question 13

What is the initial antibiotic regimen to start for FN?

Answer 13

Promptly start broad-spectrum antibiotics. Empiric = reliable coverage of most likely bugs. Bactericidal. Antipseudomonal agent. Stepwise approach if fever persists

Question 14

What is the usual oral abx used for low risk patients with FN?

Answer 14

Cipro + Amoxacillin-Clavulanate. Reassess after 3-5 days

Question 15

What are the usual choices for abx in low risk FN patients who require IV treatment?

Answer 15

Cefepime. Ceftazidime. Zosyn. Carbapenem. Aztreonam + Vancomycin (if PCN or cephalosporin allergy). Reassess after 3-5 days

Question 16

What is reassessment of antibiotic regimen during 1st week like?

Answer 16

At least 3 days of tx usually required to assess efficacy. Time to defervesce for FN cancer patients ranges from 2-7 days

Question 17

What is done for high risk FN patients who need Vanco?

Answer 17

Vancomycin + Zosyn, Cefepime or carbapenem +/- AG. Reassess after 3-5 days

Question 18

What is done for high risk FN patients who do not need Vanco?

Answer 18

Two drugs: AG + Zosyn, Cefepime, or Carbapenem. Reassess after 3-5 days

Question 19

When is Vanco usually added?

Answer 19

B-lactam allergy (vanco + Aztreonam). Catheter-related cellulitis (coag neg Staph). Known colonization w/ PCN- or Ceph-resistant penumococci or MRSA. Isolation of gram positive bacteria from blood. Severe mucositis (Ara-C). Quinolone prophylaxis for afrebrile neutropenia. Clinically unstable (hypotension, septic shock)

Question 20

What needs to be added to patients regimen if febrile through days 5-7 and resolution of neutropenia is not imminent?

Answer 20

Add antifungals with or without antibiotic change

Question 21

When can FN therapy be stopped?

Answer 21

If ANC > 500 x2 consecutive days + if afebrile for 48hrs + clinically well

Question 22

When are systemic fungal infections common in FN patients?

Answer 22

Prolonged (7+ days) and profound neutropenia. Severe mucosal damage. Underlying disease (BMT, AML). Presence of CVC, steroids, broad spectrum antibiotics exposure

Question 23

What are the most common fungal pathogens in FN patients?

Answer 23

Candida. Aspergillosis. Other molds: Fusarium, Mucor, Rhizopus

Question 24

What are the Granulocytes-CSF (Colony Stimulating Factors) used?

Answer 24

Filgrastim (Neupogen): 5mcg/kg SQ QD x7-10 days. Pegfilgrastim (Neulasta) - long acting: 6mg fixed SQ once/CT cycle or Q3 weeks

Question 25

What are the Granulocyte-Macrophage-CSF (Colony Stimulating Factors) used?

Answer 25

Sargramostim (Leukine): 250mcg/m2 SQ daily

Question 26

What is a caution with Pegfilgrastim (Neulasta) use?

Answer 26

This medication is NOT to be administered during the time interval beginning 14 days before to 24h after administration of chemotherapy

Question 27

When do you begin CSFs and for how long?

Answer 27

Begin 24-72hrs post chemo. Continue past Nadir until ANC >10,000/mcL (~7-14 days). Alternative: Use for shorter duration until clinically adequate neutrophil recovery, i.e. ANC 2-3,000/mcL

Question 28

What are the ADRs associated with CSF?

Answer 28

Fever, HA, Bone/joint pain, myalgia (tylenol can be used for these). Injection site reaction. Dyspnea, fluid retention (less common). Splenic rupture