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PDAT6 ID > 24 - Febrile Neutropenia > Flashcards

24 - Febrile Neutropenia Flashcards

1
Q

Empiric Antibiotic Treatment
PCN ALLERGY

Step 2: Febrile Neutropenia

A

Ciprofloxacin** + **Clindamycin

OR

Aztreonam** + **Vancomycin

instead of:
Cefepime / Meropenem / Imi-Cilastatin / Pip-Tazo

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2
Q

STEP 1

  • *5 Step Treatment Approach**
  • *FEBRILE NEUTROPENIA**
A

WITHIN 15 MINUTES

A) Assume Bacterial infection
fever is often the ONLY sign of infection

B) **C**ollect SAMPLES

  • *CBC + Leukocyte Differential Count** = ANC
  • *>** 2 sets of Blood Cultures

C) Perform Systemic patient Assessment
maximize chances of determining SITE of infxn / organism

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3
Q

Febrile Neutropenia PROPHYLAXIS

What to give if….
Allogenic Hematopoeietic Cell Transplant = HSCT?

A

AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN

AntiVIRAL
NOPE, only if seropositive for HSV or VZV

AntiFUNGAL
FLUCONAZOLE
CANDIDA - HSCT

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4
Q

Why does NEUTROPENIA indicate

Infection Risk?

A

Neutrophils

Innate Defense –> target Bacteria & fungi

↓Neutrophils –> INCREASING INFECTION RISK

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5
Q

OUTPATIENT TREATMENT
PCN ALLERGY

Step 5b: Reassess Therapy for Outpatient
Febrile Neutropenia

A

Goal: Defervesence within 3 days of ABx infection
if failure –> RE-ADMIT to hospital

CIPROFLOXACIN** or **LEVOFLOXACIN
+
CLINDAMYCIN
instead of Augmentin

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6
Q

STEP 5

  • *5 Step Treatment Approach**
  • *FEBRILE NEUTROPENIA**
A

Step 5
Reassess Therapy & MODIFY if necessary

Various Situations:
Dependent on clinical & microbiologic Data

Duration of Treatment:
Afebrile >2 days & ANC has recovered (> 500)

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7
Q

STEP 3

  • *5 Step Treatment Approach**
  • *FEBRILE NEUTROPENIA**
A

Step 3: ANC CALCULATION

Absolute Neutrophil Count (ANC) < 500 cells/mm3
Mature: PMN or SEGs // Immature: BANDS

Percent:
Total WBC x (%PMN/100 + %BANDS/100)

Total Number:
(PMNs + Bands) x 1,000

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8
Q

When to use
PROPHYLAXIS
for
Febrile Neutropenia

A

High Risk = Severe PROLONGED neutropenia
Predicted to have ANC < 100 cells/mm for > 7 days

Examples:

  • *HSCT**
  • *Allogenic Hemtopoietic Cell Transplant**

INDUCTION CHEMOTHERAPY
for Acute Leukemia

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9
Q

What to do if….
Identifiable cause of Fever
Ex. Pneumonia

  • *Step 5a: Reassess Therapy for INPATIENT**
  • *Febrile Neutropenia**
A

Identifiable cause of Fever
Ex. Pneumonia
VVVV
ALTER TREATMENT for SPECIFIC INFXN

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10
Q

What to do if….
Persistant fever > 4 DAYS
AFTER
Broadening Spectrum ABx / no Identified source

  • *Step 5a: Reassess Therapy for INPATIENT**
  • *Febrile Neutropenia**
A

Persistant fever > 4 DAYS
AFTER
Broadening Spectrum ABx / no Identified source
VVVV
ADD:
EMPIRIC ANTIFUNGAL THERAPY

Ex:
Cefepime + Amphotericin B

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11
Q

Empiric Antibiotic Treatment

Step 2: Febrile Neutropenia

A

1 Anti-Pseudomonal B-Lactam
C-MIP

CEFEPIME

Meropenem - Imipenem/Cilastatin
(ESBL Suspected)

  • *Pip/Tazo**
  • do not use WITH VANCO*
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12
Q

STEP 2

  • *5 Step Treatment Approach**
  • *FEBRILE NEUTROPENIA**
A

2 - Select Empiric Antimicrobial Therapy

Recommendation:

  • *ALL PATIENTS** should recieve an INITIAL IV DOSE
  • *ASAP = within 1 hour**

Most common infection = translocation across intestine
20-30% bacteremia

Goal is to Cover:
MOST COMMON (Gram POS) & MOST VIRULENT (Gram NEG)

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13
Q

OUTPATIENT TREATMENT

Step 5b: Reassess Therapy for Outpatient
Febrile Neutropenia

A

Goal: Defervesence within 3 days of ABx infection
if failure –> RE-ADMIT to hospital

CIPROFLOXACIN** or **LEVOFLOXACIN
+
AUGMENTIN
amoxicillin/clavulanate

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14
Q

Febrile Neutropenia PROPHYLAXIS

What to give if….
INDUCTION CHEMOTHERAPY for Acute Leukemia?
&
SEROPOSITIVE for HSV +/- VZV

A

AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN

AntiVIRAL
ACYCLOVIR or VALACYCLOVIR
+ Annual Flu Shot

AntiFUNGAL
POSACONAZOLE or VORICONAZOLE
for Candida +/- Aspergillus

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15
Q

What to do if….
PERSISTANT FEVER** + **HEMODYNAMICALLY UNSTABLE
Ex.
Fever > 3 days + BP dropping significantly

  • *Step 5a: Reassess Therapy for INPATIENT**
  • *Febrile Neutropenia**
A

PERSISTANT FEVER + HEMODYNAMICALLY UNSTABLE
Ex.
​ Fever > 3 days + BP dropping significantly
VVVV
BROADEN EMPERIC THERAPY
for RESISTANT - Gram +/- & Anaerobes
Ex.
MEROPENEM (for ESBL) + VANCOMYCIN

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16
Q

STEP 4

  • *5 Step Treatment Approach**
  • *FEBRILE NEUTROPENIA**
A

Step 4:
ID Candidates for OUTPATIENT Treatment

Carefully selected patients that are at:
low risk for medical complications –> ORAL ABx

17
Q

What to do if….
Febrile for 2 days + Negative Cultures

  • *Step 5a: Reassess Therapy for INPATIENT**
  • *Febrile Neutropenia**
A

Febrile for 2 days + Negative Cultures
AND
ANC > 500
VVV
MAY DISCONTINUE THERAPY

18
Q

What to do if….
PERSISTANT FEVER
but, stable & no site of infxn detected

  • *Step 5a: Reassess Therapy for INPATIENT**
  • *Febrile Neutropenia**
A

PERSISTANT FEVER
but, stable & no site of infxn detected
VVV
CONTINUE THERAPY** until **ANC > 500
+
keep looking for infxn source

19
Q

Febrile Neutropenia

DEFINITION

A

FEVER
Single reading > 38.3*C (101*F)
or a > 38*C sustained over an hour

  • *SEVERE NEUTROPENIA**
  • *ANC < 500 cells/mm3**

Seen:
CHEMOTHERAPY START** within **6 WEEKS

20
Q

Febrile Neutropenia PROPHYLAXIS

What to give if….
Allogenic Hematopoeietic Cell Transplant = HSCT?
&
SEROPOSITIVE for HSV +/- VZV

A

AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN

AntiVIRAL
ACYCLOVIR or VALACYCLOVIR
+ Annual Flu Shot

AntiFUNGAL
FLUCONAZOLE
for CANDIDA - HSCT

21
Q

When to add VANCOMYCIN?

Step 2: Empiric ABx Therapy
Febrile Neutropenia

A

HIGH RISK PATIENTS
SEPTIC (hemodynamically Unstable) = ↑Mortality risk
Suspected:
PNEUMONIA
CRSBI (Catheter related infxn)
Skin or Soft-Tissue Infxn
H/o MRSA infxn or colonization

  • Addition of VANC (for gram POS) is NOT associated w/ clinical benefit & may promote RESISTANCE
  • DO NOT USE PIP/TAZO w/ VANCOMYCIN**
22
Q

Febrile Neutropenia PROPHYLAXIS

What to give if….
INDUCTION CHEMOTHERAPY for Acute Leukemia?

A

AntiBACTERIAL:
CIPROFLOXACIN or LEVOFLOXACIN

AntiVIRAL
NOPE, only if seropositive for HSV or VZV

AntiFUNGAL
POSACONAZOLE or VORICONAZOLE
Candida +/- Aspergillus
beware of chemotherapy drug interactions

PDAT6 ID (31 decks)

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