Febrile Neutropenia Flashcards
High risk patient
–almost always admitted to hospital
• Neutropenia > 7 days
• AND profound neutropenia (ANC <100 cells/mm3) normally: 5000
• AND/OR significant medical co‐morbid conditions
• MASCC score <21
Hemotologic cancers
Consider prophy w/ quinolone and antiviral
Low risk patient
• Brief duration of neutropenia (<7 days) • No or few comorbidities • Oral therapy an option? • MASCC score >=21 Solid tumors
How to calculate ANC
(%neutrophils + %bands) x WBC
__________________
100
Empiric Therapy–what to cover?
cover Pseudomonas
also E. coli, Coag neg staph (viridins and epidermis)
High risk patient tx with Anti-pseudomonal beta-lactams + some others
Cefepime,
Piperacillin-tazobactam,
meropenem
ceftazidine
Doripenem or imipenem-cilastatin
Levo or Cipro
PCN allergy: Aztreonam
When to add Vanco?
Not recommended as part of standard tx
OK in MRSA, KPC catheter-related infection, SSTI with staph aureus, pneumonia, hemodynamically unstable, gram positive blood cultures
g-CSF
raise WBC counts
decrease likelihood of neutropenic fever
DOES NOT prevent infection
Use 24-72 hours after chemo
When to changed therapy?
Microbiological data (susept) Don't change if fever doesn't go away and stable!!
Stop Vanco–
–2-3 days after initiation if gram+ hasn’t been identified
Remain hemodynamically unstable..
..then broaden coverage for gram-neg, gram-pos, fungal, anaerobic
When to start an anti-fungal
Start if still have fever 4-7 days after starting and no identified fever source
How long to continue antibiotics
At least for duration of neutropenia (until ANC>500)
Who to give antifungal prophy to?
HSCT recipients or AML treatment or remission: Candida coverage, -conazoles
AML or MDS: aspergillus coverage with Posaconazole.
Can use flucon, itra, posa, voriconazole. Mica fungin, caspofungin
Low risk outpatient algorithm
PO Levo or Cipro + Augmentin or Cipro + Clinda Assess daily for 3 days
Low risk inpatient algorithm
Vanco not needed
Anti-pseudomonal agent
High risk algorithm
+/- vanco
Anti-pseudomonal agent
reassess vanco use after 2 days
Need fungal coverage after 4 days?
Tumor lysis syndrome (TLS) causes
Treatment related from cell rupture
Spontaneous cell lysis when demand exceeds supply
TLS releases
DNA (uric acid)
Phosphate
Potassium
Cytokines
TLS risk factors
Bulky disease LDH>1500 >>bone marrow involvement high tumor sens to chemo decreased renal func high risk cancers (Burkitt lymph, ALL, AML, CML, CLL)
Diagnosis of TLS
2+ lab abnormalities and symptoms
Uric acid>8, K>6, Phos>6.5, Ca<7 or any change 25%
TLS treatment
stop offending agents IV hydration with NS or D5W (bicarb if necessary) Allopurinol Rasburicase HyperK tx, EKG+CaGluc Calcium acetate or Lanthenum carbonate
Calculating Ca2+ during hypoalbuminemia
Ca2+corr = Ca2+serum + (0.8 x (4-albumin))
Mild: 10.5-11.9
Mod: 12-13.9
Severe=>14 or symptomatic
Hypercalcemia Risk Factors
High Ca2+ diet Poor renal excretion Thiazides, lithium, VitA&D PTH Breast cancer, myeloma, lymphoma
Hypercalc symptoms
Bones Stones Moans Groans \+arrhythmias, bradycardia, EKG signs
Hypercalcemia Tx
Stop offending agents, hydration and loop diuretics if mild/mod
IV hydration with NS if severe (14+) + bisphosphonates + calcitonin
Bisphosphonates
Zoledronic acid
Pamidronate
start immediately if severe, do not renally adjust or get dental exam.
will deposit in bone matrix
Can give another dose in 7 days
Denosumab
use if refractory to bisphosphonates
binds to RANKL on osteoblasts
No renal adjustment
Calcitonin
works quickly
give if symptomatic
inhibits osteoclast activity and GI uptake. promotes renal excretion
