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Heme/Onc > Febrile Neutropenia > Flashcards

Febrile Neutropenia Flashcards

1
Q

What is the definition of febrile neutropenia?

A 
Oral temp > 101F (38.3C)
OR
Oral T > 100.4F (38C) for one hour
PLUS
Neutrophil count < 500 
OR
Neutrophil < 1000 with a predicted nadir to < 500
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2
Q

What is nadir?

A

Lowest neutrophil count usually occurs 7-14 days post-chemotherapy

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3
Q

What is believed to cause the majority of febrile neutropenic episodes?

A

Seeding of the bloodstream from endogenous flora in the GI tract

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4
Q

What is the most commonly isolated pathogen in febrile neutropenia?

A

Coagulase negative staphylococcus

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5
Q

What is the most common fungus in febrile neutropenia?

A

Candida albicans

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6
Q

What viruses are common in febrile neutropenia?

A 
HSV
EBV
CMV
Influenza
RSV
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7
Q

What are gram positive pathogens in febrile neutropenia?

A

Coagulase negative staph
Staph aureus
Enterococcus
Strep (veridians, pneumoniae, pyogenes)

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8
Q

What are gram negative bacteria in febrile neutropenia?

A 
E coli
Klebsiella
Enterobacter
Pseudomonas aeruginosa
Citrobacter
Acinetobacter
Stenotrophomonas
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9
Q

What are the candida species in febrile neutropenia?

A

Albicans
Tropicalis
Glabrata
Krusei

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10
Q

What are invasive mold infection that are possible with profound, prolonged neutropenia?

A

Aspergillosis
Zygomycoses
Fusariosis

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11
Q

What is done in the initial patient evaluation in febrile neutropenia?

A

PE
Patient hx
Initial lab tests/procedures

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12
Q

What lab tests/procedures are done in febrile neutropenia?

A

At least 2 blood cultures (prior to initiation of abx)
Cultures from any site of suspected infection (prior to initiation of abx)
CBC w/differential
BMP
Hepatic transaminases
T bili

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13
Q

A patient that is considered high risk will get what?

A

Admission to hospital

IV abx

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14
Q

A patient that is considered low risk will get what?

A

Outpatient tx

PO abx

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15
Q

What are high risk patients?

A

Profound neutropenia expected to last more than 7 days
Significant co-morbid conditions/presenting s/sx
MASCC score < 21

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16
Q

What are considered significant co-morbid conditions/presenting s/sx?

A 
Hemodynamic instability
Oral/GI mucositis, GI sx
Mental status changes
New pulmonary infiltrates, hypoxemia, underlying lung disease
Hepatic insufficiency
Renal insuffiency
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17
Q

What are considered low risk patients?

A

Anticipated brief neutropenia
No/few co-morbidities
MASCC score greater than or equal to 21

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18
Q

When reading a MASCC score, what is considered a low risk patient?

A

21 or higher (max is 26)

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19
Q

Immediately after the blood culture, what do we do?

A

Give empiric abx

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20
Q

What are the empiric therapies for febrile neutropenia?

A 
Cefepime
Imipenem/cilastatin
Meropenem
Pip/tazo
Ceftaz
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21
Q

Empiric treatment uses which type of abx for empiric therapy?

A

Anti-pseudomonal beta-lactams

22
Q

When should vancomycin be added to empiric abx therapy?

A

Hemodynamic instability/sepsis
Radiographically documented pneumonia
Blood culture + for staph before culture finalized
Clinically suspected catheter related infection
Suspected skin/soft tissue infection
Colonization with MRSA or PCN resistant streptococcus

23
Q

What are indications for other empiric abx?

A

H/o VRE (linezolid, dapto)

H/o KPCs (polymyxin-colistin, tigecycline)

24
Q

What abx are given for outpatient tx?

A

Cipro + augmentin
FQ may be considered
Clinda may be substituted for augmentin in hypersensitivity

25
Q

What is assessed at 48 hours?

A

Cultures = abx therapy change
If vanc initiated empirically, may be stopped at 48 hours if no gram+ growth
Hemodynamically stable, consider transition to PO abx
Hemodynamically unstable patients with fever, abx coverage broadened

26
Q

When do we see oral lesions/esophagitis and how do we treat it?

A

HSV

Consider acyclovir and/or fluconazole

27
Q

When do we see ab pain and how do we treat it?

A

Neutropenic enterocolitis

Pip/tazo monotherapy

28
Q

What do we do if there is recurrent or persistent fever for > 72 hours despite empirical abx therapy warrants evaluation?

A

Additional blood cultures
Thorough search for source of infection
Non-infectious source of fever

29
Q

When is empiric antifungal coverage considered in high risk patients?

A

After 4-7 days of broad spectrum abx coverage and no identitified fever source

30
Q

If the patient is receiving fluconazole prophylaxis, what do we consider is the cause?

A

Resistant candida species or evasive fungal infection

31
Q

What do we give if the candida strain is fluconazole resistant?

A

Ampho B
Capsofungin
Voriconazole

32
Q

When do we use antibacterial prophylaxis?

A

High risk patients with expected profound and prolonged neutropenia
ANC less than or equal to 100 for > 7 days

33
Q

What medications do we prophylactically treat for febrile neutropenia?

A

FQ

34
Q

When is antifungal prophylaxis recommended?

A

For allogeneic HSCT recipients or those undergoing remission-induction or salvage induction chemotherapy for acute leukemia

35
Q

With which medication do we prophylax for fungal infections?

A

Fluconazole

36
Q

When is viral prophylaxis recommended?

A

Patients who are HSV-seropositive

37
Q

What medication is used for viral prophylaxis?

A

Acyclovir

38
Q

When should the influenza vaccine be administered?

A

Greater than 7 days post-chemo or > 2 weeks before chemo

39
Q

Which MGFs do we start 1-3 days after completion of chemotherapy cycle?

A

Filgrastim
Pegfilgrastim
Sargramostim

40
Q

When do we not use pegfilgrastim?

A

Regimens scheduled < 2 weeks apart

41
Q

What are G-CSFs?

A

Filgrastim

Pegfilgrastim

42
Q

What is GM-CSF?

A

Sargramostim

43
Q

What is G-CSF approved for?

A

Prevention of chemo-induced neutropenia

44
Q

What is GM-CSF approved for?

A

Following induction therapy for AML/stem cell transplantations

45
Q

What are the AEs of MGFs?

A 
Fever
N/V/D
Bone pain***
HTN
Hyperglycemia
46
Q

When are MGFs used as primary prophylaxis?

A

During the first cycle of myelosuppressive chemotherapy

Goal of preventing neutropenic complications

47
Q

When are MGFs used as secondary prophylaxis?

A

Subsequent chemo cycles after neutropenic fever has occurred in a prior cycle

48
Q

Above what % incidence is primary prophylaxis recommended?

A

greater than or equal to 20% anticipated febrile neutropenia

49
Q

Which patients may MGF primary prophylaxis be justified?

A 
> 65 yo receiving full dose intensity
Bone marrow involvement
Renal dysfunction
Liver dysfunction
Recent surgery or open wounds
Active infection
50
Q

By what percent does GMF use as secondary prophylaxis reduce the risk of febrile neutropenia?

A

50%

51
Q

What are RFs for poor clinical outcomes of febrile neutropenia?

A 
Age > 65
Sepsis syndrome
Severe neutropenia (ANC < 100)
Prolonged neutropenia (> 10 days in duration)
Pneumonia
Invasive fungal infection
Other clinically documented infections
Hospitalization at time of fever
Prior episode of febrile neutropenia

Heme/Onc (20 decks)

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