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Block G -- Infection > Dr. Karatzios -- Fever in Immunocompromised > Flashcards

Dr. Karatzios -- Fever in Immunocompromised Flashcards

1
Q

Define febrile neutropenia

A
  • Fever
    • ≥ 38.3 oC oral in a single measurement
    • 38 oC in 2 measurements within 1 hour

PLUS

  • Low absolute neutrophil count (ANC)
    • ≤ 500 cells/mL
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2
Q

4 causes of neutropenia secondary to cancer chemotherapy

A
  • Denuded gut secondary to chemotherapy (including mucositis)
  • Central line infections
  • Fungal organisms
  • Common organisms causing fever
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3
Q

Usual pathogen of denuded gut secondary to chemo

A

Usually gram negative enteric rods

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4
Q

Pathogens associated with central line infections causing neutropenia secondary to cancer chemo

A
  • Usually gram positive cocci (CoNS, MSSA/MRSA)
  • Pseudomonas aeruginosa
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5
Q

2 fungal organisms that can cause neutropenia secondary to cancer chemo and their origins

A
  • *Candida *spp. (from gut, from central line(s))
  • *Aspergillus *spp. (from lungs)
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6
Q

3 common organisms causing fever that can cause neutropenia secondary to cancer chemo

A
  • S. pneumoniae
  • Respiratory viruses
  • C. difficile
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7
Q

Explain the findings of unexplained fever in cancer chemo patients with febrile neutropenia

A

No bacteria ever isolated in blood culture = pieces of LPS from the gut

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8
Q

2 probably causes of fever in a NEWLY diagnosed cancer patient (no chemo yet)

A
  • Tumor/cancer
  • Community pathogens (i.e. S. pneumoniae, respiratory viruses, etc)
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9
Q

Etiology of fever without obvious symptoms in cancer chemo patients in order of what to suspect first

A
  1. Bacteria coming from a denuded gut
  2. Community-acquired sources
    • Pneumonia
    • Resp. viruses
  3. If persistent, esp. while on very extensive and broad spectum ABX, think fungal illness
    • *Candida *spp., *Aspergillus *​spp.
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10
Q

Etiology of fever in cancer patients with specific symptoms

A
  • If IV site red and/or painful, central line sepsis
  • If diarrhea, C. diff
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11
Q

Most common cause of bacteremia in cancer chemotherapy pateitns

A

CoNS

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12
Q

Etiology of fever in cancer patient with symptoms of mucositis and/or shock

A

All possible causes AND specifically Streptococcus viridans

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13
Q

Chemotherapy drug that especially has a risk for causing mucositis

A

High dose Ara-C

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14
Q

Minimum coverage for empiric antibiotic choice (3)

A
  • Bacteria from gut, including anaerobes
  • *Pseudomonas *spp.
  • Staphylococcus aureus
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15
Q

Pathogen against which there must be additional coverage for empiric ABX choice if there is the presence of mucositis or shock

A

Streptococcus viridans

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16
Q

3 organisms to consider if you know or suspect resistance for fever in cancer patients

A
  • MRSA
  • ESBL
  • VRE
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17
Q

Empiric antibiotic for NEWLY diagnosed patient coming in with fever

A

Any antibiotic that covers community organisms causing pneumonia and sepsis (i.e. Ceftriaxone IV +/- “atypical” organism coverage)

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18
Q

Empiric therapy for KNOWN cancer patients coming in with febrile neutropenia

A
  • Broad spectrum beta-lactams
    • +/- aminoglycosides IV
    • +/- vancomycin IV depending on clinical condition
  • Sometimes oral therapy used
    • i.e. Ciprofloxacin + Clindamycin
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19
Q

3 conditions in KNOWN cancer patient with febrile neutropenia for which vancomycin IV is recommended

A
  • Line sepsis
  • Septic shock
  • Known MRSA colonization
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20
Q

When is empiric antifungal treatment administered for cancer patients with fever?

A
  • Usually not given empirically IN THE BEGINNING unless there is clinical evidence for a fungal infection
  • Started if fever persists past 4 days in cancer patients with febrile neutropenia (or sooner depending on evidence)
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21
Q

3 signs of clinical evidence for a fungal infection requiring antifungal empiric treatment

A
  • Characteristic rash
  • Lung nodules on CXR
  • Positive blood culture for yeast or fungus
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22
Q

3 Tissues usually affected by *Candida *spp first before any blood tissue

A
  • Liver
  • Spleen
  • Retina
23
Q

When are imaging studies for fungal infection most sensitive and why?

A

When neutropenia has resolved as abscesses will then form

24
Q

Blood count findings of cancer patient with fever which would point to invasive aspergillosis

A
  • Severe neutropenia (ANC <100 cells/mL) AND
  • Prolonged neutropenia (> 10 days)
25
Q

2 kinds of cancer patients most often affected by invasive aspergillosis

A
  • Bone marrow transplant patients
  • Patients with AML (“strong” chemotherapy)
26
Q

Treatment for invasive aspergillosis in cancer patients with fever

A

Voriconazole IV until radiographic resolution (may take 1 - 2 months AT LEAST)

27
Q

2 situations which have an obvious clinical need for antiviral treatment

A
  • Characteristic rash (i.e. varicella/shingles or herpes)
  • Severe respiratory illness (i.e. influenza)

NOTE: No role for empiric antiviral treatment otherwise

28
Q

Duration of antimicrobial/antiviral therapy for specific illness treatment

A
  • At least 10 - 14 days AND
  • Until no fever AND
  • At least until ANC > 500 cells/mL
29
Q

Duration of antimicrobial/antiviral therapy if no bacteremia and source identified

A
  • Until no fever AND
  • At least until ANC > 500 cells/mL
30
Q

Duration of antifungal therapy if no documented disease

A

Treat until you can rule out hepatosplenic candidiasis and candidal retinitis

31
Q

3 phases of graft versus host disease

A
  1. Pre-engraftment
  2. Post-engraftment (acute)
  3. Late phase (chronic)
32
Q

2 bacterial opporunistic infections during pre-engraftment and post-engraftment phases of GVHD

A
  • Gram negative bacilli
  • Gram positiv organisms
33
Q

3 viral opporunistic infections during GVHD

A
  • Herpes simplex virus
  • Respiratory viruses
  • Enteric viruses
34
Q

2 fungal opporunistic infections during GVHD

A
  • Aspergillus
  • Candida
35
Q

2 viral opporunistic infections starting during the post-engraftment phase of GVHD

A
  • CMV
  • EBV PTLD
36
Q

4 late phase opportunistic pathogens in GVHD

A
  • Encapsulated bacteria
  • Varicella Zoster virus
  • Aspergillus species
  • Pneumocystis
37
Q

7 conditions that predispose to infection

A
  • Humoral immunity dysfunction
  • Cellular immunity dysfunction
  • Complement immunity dysfunction
  • Neutropenia (not due to chemo)
  • Hyper IgE (Job) Syndrome
  • Chronic granulomatous disease
  • Asplenia or splenic dysfunction
38
Q

4 pathogens usually involved in infection of those with humoral immunity dysfunction

A

Usually recurrent sinopulmonary infections with community organisms:

  • S. pneumoniae
  • H. influenzae
  • *Mycoplasma *spp.
  • Moraxella catarrhalis
39
Q

6 pathogens usually involved in infection of those with cellular immunity dysfunction

A

Usually organisms that require cellular immunity to be killed

  • Intracellular organisms:
    • *Salmonella *spp.
    • Listeria monocytogenes
    • *Mycobacterium *spp.
  • Fungi (including Pneumocytis jiroveci)
  • Viruses
  • Parasites (Toxoplasma gondii)
40
Q

Pathogen usually involved in infection for those with complement immunity dysfunction

A

Recurrent *Neisseria meningitidis *infections

–> Terminal Membrane Attack Complex dysfunction

41
Q

6 pathogens/infections that commonly affect those with neutropenia not due to chemo

A

Community organisms

  • S. pneumoniae
  • S. aureus
  • *Mycoplasma *spp
  • UTI
  • Respiratory viruses
  • N. meningitides
42
Q

Pathogen that affects those with hyper IgE (Job) Syndrome, and its manifestations

A

*S. aureus *(skin and severe invasive disease)

43
Q

Category of pathogens that affect those with chronic granulomatous disease (give 2 examples)

A

CATALASE positive organisms

  • S. aureus
  • *Aspergillus *spp
44
Q

4 pathogens that affect those with asplenia or splenic dysfunction

A

Encapsulated organisms

  • S. pneumonia
  • H. influenzae
  • N. meningitidis

Sickle cell disease = Encapsulated + *Salmonella spp (Salmonella *spp. osteomyelitis)

45
Q

Neonate and young infant fever: criteria for medical emergency

A

Fever in babies less than 3 months old (especially less than 6 weeks old)

46
Q

4 types of pathogens that can cause neonatal and young infant fever

A
  • Maternal stool/vaginal organisms
  • Maternal organisms
  • Neonatal HSV disease
  • Community bacteria and viruses
47
Q

3 maternal stool/vaginal organisms that can cause neonatal and young infant fever

A
  • Enteric gram negative rods
  • GBS
  • Listeria monocytogenes
48
Q

2 maternal organisms that can cause neonatal and young infant fever

A
  • *S. aureus *(MSSA or MRSA)
  • GAS
49
Q

2 manifestations of neonatal HSV disease

A
  • Profound sepsis
  • Encephalitis
50
Q

Approach to febrile neonates <1 year old

A
  • Presume serious bacterial infection
  • Full septic workup (blood, urine cultures) including LP (culture)
    • Inpatient followup + empiric ABX IV
  • CXR, nasopharyngeal viral studies, stool culture if warranted
51
Q

Approach to febrile neonates <1 month old if suspect meningitis or a “missed LP”

A

Meningitis doses of ampicillin and cefotaxime (ceftriaxone)

NOTE: Some recommend adding gentamicin especially if GBS or *Listeria *spp. strongly suspected

52
Q

Recommendations for empiric acyclovir for neonatal HSV disease

A

Currently NOT a standard of practice and does NOT appear in any neonatal sepsis/meningitis guidelines

53
Q

2 treatment regimens for empiric antibiotics in febrile babies ≥ 1 month – 3 months

A
  • Ampicillin IV + Gentamicin IV
  • Ampicillin IV + Vancomycin IV + third generation cephalosporin for meningitis (Ceftriaxone IV)

Block G -- Infection (23 decks)

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