FEBRILE NEUTROPENIA

Question 1

TRUE OR FALSE: Neutropenic patients are threatened by their microbial flora, including gram-positive and gram-negative organisms found commonly on the skin and mucous membranes and in the bowel

Answer 1

TRUE

Question 2

If the patients remain febrile after the resolution of neutropenia, what differential diagnoses should be seriously considered?

Answer 2

(1) fungal infection
(2) bacterial abscesses or undrained foci of infection
(3) drug fever (including reactions to antimicrobial agents and chemotherapy or cytokines).

Question 3

Which patients are classified as low-risk and should be treated with a broad-spectrum oral regimen?

Answer 3

Outpatients who are expected to remain neutropenic for <10 days and who do not have concurrent medical problems (such as hypotension, pulmonary compromise, or abdominal pain)

Question 4

Prophylaxis with what antibiotic regimen decreases morbidity and mortality rates among afebrile patients who are anticipated to have neutropenia of long duration.

Answer 4

Fluoroquinolone (ciprofloxacin or levofloxacin)

Question 5

Antibiotic regimens for the treatment of febrile patients in whom prolonged neutropenia (>7 days) is anticipated

Answer 5

(1) ceftazidime or cefepime
(2) piperacillin/tazobactam
(3) imipenem/cilastatin or meropenem

• All three are active against P. aeruginosa and a broad spectrum of aerobic gram-positive and gram-negative organisms
• Imipenem/cilastatin has been associated with an elevated rate of C. difficile diarrhea

Question 6

Any patient receiving more than a maintenance dose of glucocorticoids should also receive prophylactic TMP/SMX because of the risk of Pneumocystis infection

Answer 6

TRUE

• those with ALL should receive such prophylaxis for the duration of chemotherapy.

Question 7

Invasive candidal disease in neutropenic patients is usually caused by

Answer 7

C. albicans or C. tropicalis

Question 8

Serious (and sometimes fatal) infections due to HSV and VZV are well documented in patients receiving chemotherapy. What drug can be given prophylactically or as a treatment?

Answer 8

Acyclovir

Question 9

Granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor, enhance granulocyte recovery after chemotherapy. What is the indication for giving such drug?

Answer 9

only when neutropenia is both severe and prolonged

Question 10

It refers to the clinical presentation of fever and <1500 granulocytes/μL

Answer 10

Febrile neutropenia

Question 11

A neutropenic patient has persistent fever despite broad-spectrum antibiotics, and no infectious site is found. What is the next step?
A) Discontinue antibiotics
B) Add a broad-spectrum antifungal agent
C) Start antiviral therapy
D) Perform emergency surgery

Answer 11

Answer: B) Add a broad-spectrum antifungal agent
Rationale: If a febrile neutropenic patient remains febrile despite empiric antibiotic therapy and no infection source is found, fungal infections (e.g., Candida, Aspergillus) should be suspected, warranting antifungal coverage.

Question 12

When can antibiotics be stopped in a neutropenic patient with fever?
A) After 24 hours of therapy
B) After 48 hours, regardless of symptoms
C) After 72 hours if the patient is stable and afebrile
D) Only when granulocyte count returns to normal (>1500/μL)

Answer 12

Answer: C) After 72 hours if the patient is stable and afebrile
Rationale: If a patient remains stable and afebrile for 72 hours, antibiotics can be discontinued with careful observation. However, those who are unstable or have persistent fever require continued therapy.

Question 13

What is the most appropriate management for a neutropenic patient with an obvious infectious site?
A) Discontinue broad-spectrum antibiotics and treat only the identified infection
B) Treat the infection with the best available antibiotics while maintaining broad-spectrum coverage
C) Start antiviral therapy instead of antibiotics
D) Wait for granulocyte recovery before initiating targeted therapy

Answer 13

Answer: B) Treat the infection with the best available antibiotics while maintaining broad-spectrum coverage
Rationale: Even if an infection site is found, narrowing the antibiotic spectrum too soon can be dangerous in neutropenic patients. Coverage should remain broad to protect against potential secondary infections.

Question 14

What is the ultimate endpoint for continuing antibiotic therapy in febrile neutropenia?
A) When fever resolves
B) When granulocyte count is >500/μL
C) When cultures return negative
D) After 5 days of therapy

Answer 14

Answer: B) When granulocyte count is >500/μL
Rationale: The key determinant for stopping antibiotics in neutropenic patients is resolution of neutropenia (granulocyte count >500/μL), as low neutrophils indicate an ongoing infection risk.

Question 15

What is the definition of febrile neutropenia?
A) Fever with granulocyte count <2000/μL
B) Fever with granulocyte count <1500/μL
C) Fever with granulocyte count <500/μL
D) Fever with granulocyte count <1000/μL

Answer 15

Answer: B) Fever with granulocyte count <1500/μL
Rationale: Febrile neutropenia is defined as fever and a granulocyte count of <1500/μL, indicating a high risk of infection due to an impaired immune system.

Question 16

Which type of pathogens are the most common cause of infection in febrile neutropenia?
A) Anaerobic bacteria
B) Aerobic bacteria (both gram-positive and gram-negative)
C) Fungal infections
D) Viral infections

Answer 16

Answer: B) Aerobic bacteria (both gram-positive and gram-negative)
Rationale: The most common pathogens in febrile neutropenia are aerobic bacteria, including gram-positive (e.g., Staphylococcus) and gram-negative organisms (e.g., Pseudomonas aeruginosa).

Question 17

When can antibiotic therapy be discontinued in a febrile neutropenic patient?
A) After 24 hours if afebrile
B) After 48 hours regardless of symptoms
C) After 72 hours if afebrile and stable
D) Only after neutrophil count returns to normal (>1500/μL)

Answer 17

Answer: C) After 72 hours if afebrile and stable
Rationale: It is reasonable to stop antibiotics after 72 hours if the patient is afebrile and stable, though careful observation is required.

Question 18

Which of the following is a potential cause of persistent fever after neutropenia resolves?
A) Fungal infection
B) Bacterial abscess
C) Drug fever
D) All of the above

Answer 18

Answer: D) All of the above
Rationale: Persistent fever after neutropenia resolves can be due to:

Fungal infection (e.g., Candida, Aspergillus)
Bacterial abscesses or undrained infections
Drug fever, including reactions to chemotherapy or antimicrobial agents.

Question 19

Which antibiotic regimen is appropriate for febrile neutropenia when prolonged neutropenia (>7 days) is expected?
A) Amoxicillin-clavulanate
B) Vancomycin alone
C) Ceftazidime, cefepime, piperacillin/tazobactam, or a carbapenem
D) Azithromycin

Answer 19

Answer: C) Ceftazidime, cefepime, piperacillin/tazobactam, or a carbapenem
Rationale: These antibiotics cover Pseudomonas aeruginosa and a broad range of aerobic gram-positive and gram-negative bacteria, making them the preferred choices.

Question 20

Which class of antifungal agents is most useful for treating azole-resistant Candida and Aspergillus infections?
A) Echinocandins (e.g., caspofungin)
B) Fluconazole
C) Amphotericin B
D) Itraconazole

Answer 20

Answer: A) Echinocandins (e.g., caspofungin)
Rationale: Echinocandins are the best choice for azole-resistant Candida and Aspergillus infections due to their broad antifungal activity.

Question 21

Which antiviral agent is commonly used for prophylaxis and treatment of HSV and VZV infections in neutropenic patients?
A) Oseltamivir
B) Ganciclovir
C) Acyclovir
D) Ribavirin

Answer 21

Answer: C) Acyclovir
Rationale: Acyclovir is widely used for HSV (herpes simplex virus) and VZV (varicella-zoster virus) infections in neutropenic patients, either therapeutically or prophylactically.

Question 22

Which prophylactic measure should be taken in neutropenic patients receiving glucocorticoids for lymphoma treatment?
A) Antifungal therapy
B) TMP/SMX (trimethoprim/sulfamethoxazole) for Pneumocystis prophylaxis
C) Fluoroquinolone therapy
D) Routine IV immunoglobulin

Answer 22

Answer: B) TMP/SMX (trimethoprim/sulfamethoxazole) for Pneumocystis prophylaxis
Rationale: Patients on glucocorticoids (e.g., for lymphoma treatment) are at increased risk of Pneumocystis jirovecii pneumonia (PJP) and should receive TMP/SMX prophylaxis.

Question 23

When should granulocyte colony-stimulating factor (G-CSF) be used in neutropenic patients?
A) Always, to speed up recovery
B) Only when neutropenia is severe and prolonged
C) Only when fever is present
D) In all patients with neutropenia, regardless of severity

Answer 23

Answer: B) Only when neutropenia is severe and prolonged
Rationale: G-CSF is recommended only for severe and prolonged neutropenia to enhance granulocyte recovery after chemotherapy.

Question 24

When should primary CSF administration be considered in chemotherapy patients?
A) For all patients receiving chemotherapy
B) Only if febrile neutropenia risk is ≥20%
C) Only if the patient has a fever
D) For every patient over 50 years old

Answer 24

Answer: B) Only if febrile neutropenia risk is ≥20%
Rationale: Primary CSF administration is not routinely needed but is recommended when the risk of febrile neutropenia is ≥20%, as these patients are at higher risk of complications.

Question 25

In which scenario is secondary CSF administration recommended?
A) If febrile neutropenia has previously occurred
B) In all cases of neutropenia, regardless of severity
C) If neutropenia is present but afebrile
D) Only for neutropenia due to infections

Answer 25

Answer: A) If febrile neutropenia has previously occurred
Rationale: Secondary CSF administration is used when febrile neutropenia has already occurred in previous chemotherapy cycles to prevent recurrence.

Question 26

When is CSF therapy NOT needed?
A) Short-duration neutropenia without fever
B) Febrile neutropenia with clinical deterioration
C) Bone marrow transplantation
D) Myelodysplastic syndromes with recurrent infections

Answer 26

Answer: A) Short-duration neutropenia without fever
Rationale: Short-duration neutropenia without fever does not require CSF therapy, as it typically resolves on its own.

Question 27

Which of the following is NOT an indication for G-CSF therapy?
A) Mobilization of stem cells from bone marrow
B) Hastening myeloid recovery in chemotherapy-induced neutropenia
C) Routine use in afebrile neutropenic patients
D) Use in prolonged neutropenia that delays chemotherapy

Answer 27

Answer: C) Routine use in afebrile neutropenic patients
Rationale: CSF therapy does not provide benefits in afebrile neutropenic patients and is not routinely recommended in these cases.

Question 28

When should CSF therapy be initiated in chemotherapy patients?
A) Concurrently with chemotherapy
B) 24–72 hours after chemotherapy
C) Only when neutrophil count drops below 5,000/μL
D) After fever develops

Answer 28

Answer: B) 24–72 hours after chemotherapy
Rationale: CSF therapy should be started 24–72 hours after chemotherapy to help support neutrophil recovery. It should not be used concurrently with chemotherapy.

Question 29

What is the recommended dose of G-CSF for neutropenic patients?
A) 5 mg/kg per day subcutaneously
B) 250 mg/m² per day intravenously
C) 100 mg per day orally
D) 6 mg pegfilgrastim every 12 hours

Answer 29

Answer: A) 5 mg/kg per day subcutaneously
Rationale: The standard G-CSF dosage is 5 mg/kg per day subcutaneously. Pegfilgrastim is given as a single 6 mg dose 24 hours after chemotherapy.

Question 30

In which condition is GM-CSF NOT recommended?
A) Febrile neutropenic patients
B) Acute myeloid leukemia (AML)
C) Myelodysplastic syndromes
D) Stem cell transplantation

Answer 30

Answer: B) Acute myeloid leukemia (AML)
Rationale: GM-CSF is of no benefit in AML and may even be harmful. G-CSF is of minor or no benefit in AML as well.