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PHRM 865 > Immunocompromised Hosts (Kays) > Flashcards

Immunocompromised Hosts (Kays) Flashcards

1
Q

Define “neutropenia”.

A

abnormal reduction in the number of neutrophils circulating in peripheral blood

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2
Q

What ANC count qualifies as neutropenic?

A

< 1000/mm3

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3
Q

How do you calculate ANC?

A

ANC = WBC x (% polys + % bands)

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4
Q

There is a high risk of infection in patients with ANC < ______ cells/mm3

A

500

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5
Q

Risk of infection and death are greatest in patients with ANC < ____ cells/mm3.

A

100

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6
Q

Patients with severe neutropenia for more than _________ days are at high risk for serious infections.

A

7-10

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7
Q

What bacteria are most common in neutropenia?

A
  • S. aureus
  • S. epidermidis
  • streptococci
  • enterococci
  • E. coli
  • K. pneumoniae
  • P. aeruginosa
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8
Q

What fungi are most common in neutropenia?

A
  • Candida
  • Aspergillus
  • Zygomycetes (Mucor, Rhizopus)
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9
Q

What virus is most common in neutropenia?

A

herpes simplex virus (HSV)

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10
Q

Defects in T-lymphocyte and macrophage function are related to what type of immunity?

A

cell-mediated immunity

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11
Q

What type of immunity is negatively impacted by underlying disease (Hodgkin’s lymphoma) or immunosuppressive drug therapy in transplant patients?

A

cell-mediated immunity

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12
Q

Defects in T-lymphocyte and macrophage function result in reduced ability of the host to defend against ____________ pathogens.

A

intracellular

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13
Q

What bacterial pathogens are implicated in defects in T-lymphocyte and macrophage function (cell-mediated immunity)?

A
  • Listeria
  • Nocardia
  • Legionella
  • Mycobacteria
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14
Q

What fungal pathogens are implicated in defects in T-lymphocyte and macrophage function (cell-mediated immunity)?

A
  • C. neoformans
  • Candida
  • Histoplasma capsulatum
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15
Q

What viral pathogens are implicated in defects in T-lymphocyte and macrophage function (cell-mediated immunity)?

A
  • CMV
  • VZV
  • HSV
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16
Q

What protozoal pathogen is implicated in defects in T-lymphocyte and macrophage function (cell-mediated immunity)?

A

Pneumocystis jiroveci

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17
Q

Defects in B-cell function are related to what type of immunity?

A

humoral immunity

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18
Q

Underlying disease (multiple myeloma, chronic lymphocytic leukemia), splenectomy, and immunosuppressive therapies (steroids, chemotherapy) can all lead to which defects?

A

defects in B-cell function (humoral immunity)

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19
Q

What bacterial pathogens (encapsulated) are implicated in defects in B-cell function (humoral immunity)?

A
  • S. pneumoniae
  • H. influenzae
  • N. meningitidis
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20
Q

What pathogens are implicated in destruction of the skin as a protective barrier?

A
  • S. aureus
  • S. epidermidis
  • Candida species
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21
Q

What bacterial pathogens are implicated in the destruction of mucus membranes of the oropharynx and GI tract as protective barriers?

A
  • S. aureus
  • S. epidermidis
  • Enterobacteriaceae
  • streptococci
  • P. aeruginosa
  • Bacteroides species
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22
Q

What fungal pathogens are implicated in the destruction of mucus membranes of the oropharynx and GI tract as protective barriers?

A

Candida species

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23
Q

What viral pathogen is implicated in the destruction of mucus membranes of the oropharynx and GI tract as protective barriers?

A

HSV

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24
Q

What bacterial pathogens are implicated in solid organ transplant?

A
  • S. aureus
  • S. epidermidis
  • Enterobacteriaceae
  • P. aeruginosa
  • Bacteroides species
25
What fungal pathogens are implicated in solid organ transplant?
*Candida* species
26
What viral pathogen is implicated in solid organ transplant?
HSV
27
What is the most common colonization site for infection in cancer patients?
GI tract
28
Bacteremias are caused predominantly by normal gut flora, and develop as a result of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
microbial translocation across injured GI mucosa
29
Oropharyngeal flora rapidly change to primarily ______________ in hospitalized patients.
Gram-negative bacilli
30
Febrile episodes in neutropenic cancer patients are attributed to _____________ documented infection in only 30-40% of cases.
microbiologically
31
45-70% of bacteremic episodes in cancer patients are due to \_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Gram-positive cocci
32
Why are 45-70% of bacteremic episodes in cancer patients are due to gram-positive cocci?
* use of indwelling central/peripheral IV catheters * use of broad spectrum antibiotics with poor gram-positive activity * higher rates of mucositis caused by aggressive cancer treatments * prophylaxis with Bactrim or fluoroquinolones
33
What is the primary risk factor for invasive aspergillosis?
prolonged neutropenia
34
Invasive *Aspergillus* infection is seen primarily in patients with ______________ and undergoing \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
hematologic malignancies; HSCT
35
*Aspergillus* is acquired by inhalation of airborne \_\_\_\_\_\_\_.
spores
36
What is the most important clinical finding of infection in neutropenic cancer patients?
fever
37
In order for a neutropenic cancer patient to be considered low-risk for infection, what criteria must be met?
* neutropenia for 7 days or less * no/few comorbidities * clinically stable at onset of fever * no identified focus of infection or simple infection (e.g., UTI)
38
In order for a neutropenic cancer patient to be considered high-risk for infection, what criteria must be met?
profound (ANC ≤ 100 cells/mm3 ) AND prolonged neutropenia (\> 7 days) and/or significant commodities (hypotension, pneumonia, new-onset abdominal pain, neurologic changes)
39
What regimen should be given for initial management of febrile neutropenia in low-risk patients with adequate outpatient infrastructure who are candidates for an oral regimen?
oral FQ + Augmentin
40
What regimen should be given for initial management of febrile neutropenia in low-risk patients with inadequate outpatient infrastructure who are not candidates for an oral regimen?
Inpatient IV antibiotics (monotherapy) * Zosyn * antispeudomonal carbapenem * cefepime * ceftazidime
41
What regimen should be given for initial management of febrile neutropenia in high-risk patients?
Inpatient IV antibiotics (monotherapy) * Zosyn * pseudomonal carbaoenem * cefepime * ceftazidime
42
What should be added to initial febrile neutropenia treatment in high-risk patients with cellulitis, pneumonia, severe sepsis/shock, gram-positive bacteremia, suspected IV catheter infection, known MRSA colonization, or resistant streptococci?
IV vancomycin
43
What should be added to initial febrile neutropenia treatment in high-risk patients with septic shock, gram-negative bacteremia, or pneumonia?
aminoglycoside or antipseudonomal fluoroquinolone
44
What are the options for beta-lactam monotherapy as an empiric antibiotic regimen for febrile neutropenia?
* **ceftazidime** 2 g q8h * **cefepime** 2 g q8h * **Zosyn** 4.5 g q6h * **imipenem** 500 mg q6h * **meropenem** 1 g q8h
45
Does the IDSA recommend vancomycin or other gram-positive agents as a standard part of the initial antibiotic regimen for febrile neutropenia?
no
46
What are some situations that would warrant the addition of gram-positive agents to an empiric regimen for febrile neutropenia?
* hemodynamic instability/other evidence of severe sepsis * radiographically documented pneumonia * positive blood cultures for gram-positive pathogen before final identification and susceptibility test results are known * clinically suspected serious catheter-related infection (e.g. cellulitis around the catheter entry/exit site) * skin/soft tissue infection at any site * colonization with MRSA, VRE, or PRSP * severe mucositis (if FQ prophylaxis has been given or if ceftazidime used as empiric therapy)
47
What is the preferred empiric regimen for febrile neutropenia in penicillin-allergic patients?
ciprofloxacin + aztreonam + vancomycin
48
In febrile neutropenia, we should re-evaluate the clinical status of the patient after _________ of empiric antimicrobial therapy.
48-72 hrs
49
What therapy additions can be considered if a febrile neutropenia patient is found to have MRSA after empiric therapy?
* vancomycin * linezolid * daptomycin
50
What therapy additions can be considered if a febrile neutropenia patient is found to have VRE after initiation of empiric therapy?
* linezolid * daptomycin
51
What therapy additions can be considered if a febrile neutropenia patient is found to have an ESBL producer after initiation of empiric therapy?
carbapenem
52
What therapy additions can be considered if a febrile neutropenia patient is found to have a KPC producer after initiation of empiric therapy?
* ceftazidime/avibactam * meropenem/vaborbactam * imipenem/cilastatin/relebactam
53
In febrile neutropenia, persistence of fever or development of new fever during broad-spectrum antibacterial therapy may indicate the presence of a __________ infection.
fungal
54
What two viruses should be evaluated in neutropenic patients with vesicular or ulcerative skin or mucosal lesions?
HSV or VZV
55
What drug should be initiated if a neutropenic patient is found to have HSV/VZV?
acyclovir
56
What drug should be initiated in a neutropenic patient found to have CMV?
ganciclovir
57
What is the most important determinant of patient outcomes in febrile neutropenia?
resolution of neutropenia
58
Annual influenza vaccination with _________ vaccine is recommended for all neutropenic patients.
inactivated

PHRM 865 (59 decks)

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