Febrile Neutropenia EXAM 2 Flashcards
What is the definition of Neutropenia?
Absolute Neutrophil Count (ANC) < 500
less than 0.5 x 10^9/L
or
< 1000 (1 x 10^9/L) with expected fall to <500 in the next 48 hours
for neutropenic fever:
they also have to have a temperature of >100.4°F (38°C)
How many days after chemotherapy do you expect the lowest point of ANC (nadir)?
10-14 days after chemo
When is the risk for mucositis high after chemotherapy?
10-14 days after chemo
bc the mucsoal cells (rapidly dividing) are killed by the drugs
-risk for infections
-risk for mucositis
What is the ANC of a patient with a
WBC = 1.2 x 10^9/L with 10% neutrophils, 80% lymphocytes, 10% monocytes, & 0% bands?
1200 is the total number of WBC (contains neutrophils, eosinophils, basophils, lymphocytes, monocytes)
10% of 1200 = 120
What is the ANC of a patient with a
WBC = 1.2 x 10^9/L with 10% neutrophils, 70% lymphocytes, 10% monocytes, & 10% bands?
total = 1200
10% neutrophils = 120
10% bands (immature neutrophils) = 120
ANC = 240
What are the risk factors of neutropenic fever?
-age (old bone marrows, take longer to recover)
-chemotherapy regimen (some are more myelosuppressive, # of cycles)
-type of malignancy (hematologic at highest risk)
-concomitant radiation (depending where in the body, some bones have more bone marrow)
Which pathogens should be covered with Febrile Neutropenia?
often from our own cavity or GI -> need broad coverage
Gram + with MSSA and MRSA
Gram - E. coli, Pseudo, Klebsiella
Which pathogens should be covered with prolonged leukopenia and lymphopenia
-Fungus
-Viruses (prolonged lymphopenia)
in addition to Gram (+) and (-)???
Factors that make a patient high-risk for febrile neutropenia
-hypotension (SBP <90)
-COPD
-hematological or solid tumor with previous fungal infection
-dehydration
-hospital
-age >60y
How are high and low-risk patients treated differently?
high risk: need IV
most patients are high risk, if in the hospital they are high hrisk
low risk: oral antibiotics
Rank these patients from highest (at the top) to lowest risk of neutropenic fever.
A 65-year-old male receiving cytarabine & doxorubicin for acute leukemia.
A 50-year-old receiving their 4th cycle of doxorubicin, docetaxel, & cyclophosphamide for breast cancer.
A 50-year-old receiving their 1st cycle of doxorubicin and cyclophosphamide for breast cancer.
A 65-year-old male receiving cytarabine & doxorubicin for acute leukemia
-age is higher
-acute leukemia (blood cancer) treatment has a higher risk for neutropenia
Which pathogen is NOT covered by Cefepime?
anaerobes
if anaerobes need to be covered:
go with Pip/Tazo, it covers everything Cefepime covers + anaerobes
What is different about the coverage profile of Meropenem compared to Pip/tazo?
Meropenem has the same coverage as Pip/tazo
+ ESBL
What is the dose of Pip/Tazo used in patients with Febrile neutropenia?
4.5 g IV Q6h
renal dose adjustment: 3.375 g IV Q6h
Broad spectrum PO regimen
Augmentin + Cipro
Gram +: Augmentin (clavulanate gives some anaerobic coverage)
Pseudomonas and other Gram (-) : Ciprofloxacin
-treat until ANC >500
What are the antipseudomonal ß-lactams used for neutropenia high-risk patients?
-Pip/Tazo
-Cefepime
-Meropenem
-Imipenem/cilastatin (not often used)
if they are septic, have persistent fever, culture is growing gram (-) add gram (-) coverage
-Aminoglycoside
-Cipro
What is the dose of Cefepime used in patients with Febrile neutropenia?
2g IV Q8h
What are the 6 criteria that determine Vancomycin treatment?
!!!
- pneumonia
- suspected line infection (central catheter, or port placed)
- blood culture is growing gram (+)
- hx of MRSA, resistant strep pneumo
- septic, hemodynamically unstable, low BP, high HR
- skin and soft tissue infection
use broad spectrum antibiotic + VNC
-check the WBC and temperature, check antibiotics if no improvement after 3 days based on the culture
When do we need Febrile Neutropenia prophylaxis, and which drugs are used?
-if we think the ANC will be below 100 for a week
-drug of choice: Levofloxacin
others: Cipro
-Antifungal: Flucanozole
-Antiviral: Acyclovir
(consider antifungal, antiviral for hematopoietic stem cell transplant (HSCT) patients)
What is the dose for Cipro and Levo in Febrile Neutropenia prophylaxis?
Cipro: 500 mg Q12
Levo: 500 or 750 mg daily
Which cancer diseases are known to cause febrile neutropenia for more than a week and may require prophylaxis?
-acute leukemia
-some lymphomas
When is prophylaxis for Pneumocystis jirovecii pneumonia PJP required?
-ALL (acute lymphocytic leukemia) patients
-pts on fludarabine
-pts on alemtuzumab
-temozolomide for Glioblastoma treatment
-prednisone equivalent 20 mg /day for 1 month
Which drug is used for PJP prophylaxis? Which ones in case of an allergy to the preferred drug?
Bactrim DS (160TMP/800 SMX) daily M-W-F
or BID for Sat/Sun
in case of sulfa allergy
-inhaled pentamidine 300 mg
-Dapsone
Which drugs should be avoided in febrile neutropenia patients to assess their fever?
NSAIDs
Tylenol
bc we want to assess the patient’s fever, they are antipyretic
Know which antibiotics to use in a penicillin and cephalosporin allergy
