Exam 2 Neutropenic Fever

Question 1

define neutropenic fever

Answer 1

• neutropenia: Absolute neutrophil count (ANC) < 500 cells/mm3 or < 1000 cells/mm3 expected to drop to < 500 cells/mm3
• fever: Single oral temperature > 38.3° C (101° F) OR a temperature > 38.0° C (100.4° F) for ≥ 1 hour

Question 2

risk factors for infection based on ANC

Answer 2

• 50% of patients with an ANC < 500/mm3 and a fever have an infectious process
• Patients with an ANC < 100/mm3 for greater than 3 weeks have approximately a 100% infection rate

Question 3

risk factors for infection

Answer 3

• Rapid decline in ANC
• Impaired immunity
• Loss of protective barriers
• Alteration of normal flora
• Blood products
• Type of chemotherapy
• Radiation
• Impaired drug elimination
• Decreased marrow reserve

Question 4

common pathogenic organisms

Answer 4

• Gram +: S. aureus, S. epidermidis, S. pneumoniae, Viridans group, Enterococcus
• Gram -: E. coli, Klebsiella, Pseudomonas aureginosa

Question 5

What MUST your antibiotic treatment cover?

Answer 5

Pseudomonas

Question 6

possible but rare pathogens

Answer 6

• Anaerobes
• Fungi
• Viral

Question 7

Prophylaxis for low neutropenic fever risk

Answer 7

• none
• can treat out-pt w/ cipro _ amox/calv
• give clinda is pt has PCN allergy

Question 8

Prophylaxis for intermediate neutropenic fever risk

Answer 8

• consider
• characteristics:
  • Autologous HSCT
  • Lymphomas
  • CLL
  • Purine analogue therapy
  • Neutropenic 7-10 days

Question 9

characteristics for high neutropenic fever risk

Answer 9

• Allogeneic HSCT
• Acute leukemia
• Alemtuzumab therapy
• GVHD treated with steroids
• Neutropenic >10 days

Question 10

What is considered low risk?

Answer 10

Score ≥ 21 is low risk

Question 11

Prophylaxis for high neutropenic fever risk monotherapy

Answer 11

- Initial management of uncomplicated neutropenic fever
• Cefepime 
• Ceftazidime 
• Imipenem 
• Meropenem 
• Piperacillin / tazobactam

Question 12

Prophylaxis for high neutropenic fever risk duotherapy

Answer 12

• Any monotherapy + aminoglycoside

* Ciprofloxacin + antipseudomonal penicillin

Question 13

Prophylaxis for high neutropenic fever risk duotherapy w/ vanc indication

Answer 13

Vanc+ 
• Cefepime
• Ceftazidime
• Imipenem-cilastatin 
• Meropenem
• +/- Aminoglycoside
• Antipseudomonal penicillin + Aminoglycoside

Question 14

Ceftazidime dosing

Answer 14

2 g IV Q 8 hours

Question 15

Cefepime dosing

Answer 15

2 g IV Q 8 hours

Question 16

Meropenem dosing

Answer 16

1-2 g IV Q 8 hours

Question 17

Imipenem-cilistatin dosing

Answer 17

0.5 g IV Q 6 hours

Question 18

Piperacillin / tazobactam

Answer 18

3.375 g IV q 6h

Question 19

Cipro dosing

Answer 19

400 mg IV q 8h

Question 20

indications for vanco

Answer 20

• Hemodynamic instability or other evidence of severe sepsis
• Pneumonia documented radiographically
• Positive blood culture for gram-positive bacteria, before final identification and susceptibility testing is available
• Clinically suspected serious catheter-related infection
• Skin or soft-tissue infection
• MRSA, VRE, or PCN-resistant Streptococcus pneumoniae colonization
• Severe mucositis if FQ prophylaxis was given

Question 21

vanc dosing and goal trough

Answer 21

• 15 mg/kg

- Goal trough 10-20 mg/L (aim for 15 mg/L)

Question 22

vanc alternatives

Answer 22

• Linezolid 600 mg PO/IV every 12 h
• Daptomycin 4-6 mg/kg Day
• Tigecycline 100 mg load then 50 mg every 12 h (not recommended for bloodstream infections)

Question 23

What steps can you take if pt has fever after 3-5 days of therapy?

Answer 23

• Continue initial antibiotics
• Change antibiotics
• Add antifungal
  Coverage +/- antiviral coverage

Question 24

How long should you give antibiotics for even if pt is afebrile?

Answer 24

minimum of 7 days

Question 25

Which antifungal is the drug of choice against apergillus?

Answer 25

voriconazole

Question 26

highlighted antifungals on his slide

Answer 26

- voriconazole - amphotericin B (lipid) - capsofungin