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PHRM 865: Theraputics V > Lecture 29: Immuncomp Host > Flashcards

Lecture 29: Immuncomp Host Flashcards

1
Q

What is the definition of someone that has Neutropenia?

A
  • ANC less than 1000 mm3
  • ANC = WBC x (%poly + %bands)

Those with severe neutropenia for more then 7-10 are at the highest risk fro serious infections

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2
Q

What are some of the common pathogens in Neutropenia?

Bacteria? Fungi? Virus?

A
  • Bacteria: S. Aureus, S. Epidermidis, Strep, Entercocci, Enterobacterales, P. Aeruginose
  • Fungi: Candida, Aspergillus, Mucor, Rhizopus
  • Viruses: HSV
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3
Q

What are some of the Immune System Defects that can happen to someone that has Neutropenia?

T-cells? B-cells?

A
  • T-cells [cell-medicated immunity]: decreases that immunity making the host not fight intracellular pathogens [Listeria, Nocardia, Legionalla, Mycobacteria, C. Neoformans…]
  • B-cell [humoral immunity]: based on encapsulated pathogens [S. Pneumoniae, H. flu, N. Meningitis]
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4
Q

What are some of the way that destruction of Protective barriers can have an effect on Neutropenia?

Skin? Mucus Membrane? Surgery?

A
  • Skin: Anything that breaks skin = increase risk of pathogens [S. Aureus, S. Epidermidis, Candida]
  • Mucus Membrance: Things that affects the mouth or GI [S. Aureus, S. Epidermidis, Enterbacterales, Strep, Candida, HSV]
  • Surgery: Obviously breaking into the body [S. Aureus, S. Epidermidis, Enterobacterales, P. Aeruginose, Bacteorides, Candida, HSV]
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5
Q

What is the Epidemiology of infections in Neutropenic Cancer Patients?

A
  • Infection is leading death in cancer patients
  • Commonly in the lungs, skins, mouth, nose, GI
  • Microbiologically Documented 1/3 of the time
  • Gram (+) Cocci are the most common
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6
Q

What is the etiology for infections in Neutropenic Cancer Patient?

A
  • S. Aureus [MRSA]
  • Virdians [b-lactam resistant??]
  • Enterbacterales [E. Coli and Kleb the most common]
  • P. Aeruginosa
  • VRE, Lactobacillus, Strentrophomonas
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7
Q

What are the two most common Invasive Fungal Infections in Neutropenia?

A
  • Candida Albacins [most common - may get into the throat, blood, organs]
  • Apsergillus [from inhalation,Prolonged Neutropenia is a major risk factor]
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8
Q

What is important to know about the Herpes Simplex Virues in Neutropenia?

A
  • Mainly in those that have had herps
  • Untreated may go to esophagus
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9
Q

What is important to know about Pneumocystis Jirovecii & Toxoplasma Gondii in Neutropenia?

A
  • Routine Prophylaxis with Bactrim is good
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10
Q

What are some of the Clinical Presentations for someone with neutropenia?

A
  • FEVER; the most important [maybe only]
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11
Q

What are some fo teh Labs and Diagnostic Test that should be done for someone with neutropenia?

A
  • Blood cultures [at least 2 sets; multi-line = get from all]
  • CBC
  • CXR
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12
Q

What are some of the goals of antimircobial therapy for those managing febrile episodes of neutropenia?

A
  • Prvent death?? [duh]
  • Prevent breakthrough
  • Treat infection
  • Reduce Morbidity
  • Stewardship
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13
Q

What does it mean when a patient is low risk after finding out if they have a Fever and are Neutropenic?

A
  • Neutropenia < 7d, stable, no comorbidites, outpatient fever onset
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14
Q

For the Low Risk Neutropenic Patient, what is the treatment for adequate outpatient infrastructure?

A
  • PO Levo or Cipro + Augmentin; Then
  • Observe for 24h –> still stabe then send home
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15
Q

For the Low Risk Neutropenic Patient, what is the treatment for Inadequate outpatient infrastructure?

A
  • Inpatient IV [Pip/tazo, Cefepime, Ceftazidime, Mero, Imip]; then
  • Step down when good [no fever for < 72h, (-) cultures, PO meds]
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16
Q

What does it mean when a patient is high risk after finding out if they have a Fever and are Neutropenic?

A
  • Neutropenia > 7d, unstable, comorbidites, inpatient fever onset

MASCC < 21

17
Q

For the High Risk Neutropenic Patient, what is the treatment?

A
  • Inpatient IV [Pip/Tazo, Mero, Imip, Cefepime, Ceftazidime]; then
  • (+) IV Vacnomycin [for cellulitis, pnumonia, severe sepsis, MRSA…]; OR
  • (+) AG or Levo/Cirpo [Gram (-)]
18
Q

What is the Empiric Antibiotic Regimens: b-lactam monotherapy for the empiric treatment of Febrile Neutropenia?

Advantages? Disadvantages?

A
  • Ceftazidime 2g q8h; Cefepime 2g q8h; Pip/Tazo 4.5g q6h; Imip 500mg q6h; Mero 1g q8h
  • Advantages: All work the same, lower drug toxicities, less $$
  • Disadvantages: Low gram (+), no possible additive effects, some resistance
19
Q

What is the Empiric Antibiotic Regimens: Addition of Vancomycin to antipseudomonal b-lactam for the empiric treatment of Febrile Neutropenia?

A
  • NOT recommended Vancomycin or other gram (+) agents as part of the INITIAL regimen
20
Q

What is the Empiric Antibiotic Regimens: Penicillin-allergic patients for the empiric treatment of Febrile Neutropenia?

A
  • AVOID b-lactams & carbapenems in history of hypersensitivity
  • Cipro + Aztreonam + Vancomycin
21
Q

What is some of the management of antimicrobial therapy after the start of empiric therapy?

MRSA? VRA? ESBL? KPC?

A
  • MRSA: + Vancomycin, Linezolid or Daptomycin
  • VRE: + Linezolid or Daptomycin
  • ESBL: + Carbapenem
  • KPC: + Ceftazidime/Avibactem, Meropenem/Vaborbactam, Imipenem/Cilastatin/Relabactam, Cefederocol

Determine this within 48-72 hours

22
Q

What should you do for the initiation of antufungal treatment and what are some of the treatment options?

-

A
  • Begin empiric for those that have a fever after 4-7 days
  • Treatment: AMP B, Azoles, Echinocandins
  • Continue for 2 weeks in absense of fungal infections
23
Q

What should you do for the initiation of antiviral treatment and what are some of the treatment options?

A
  • Start aggressive therpay to help with healing and prevent dissemination
  • HSV, VZV: Acyclovir [or Valacyclovir]
  • CMV: Ganciclovir [or Valganciclovir]
24
Q

What is important to note about Catheter-Related Bacteremia?

what is the pathogen? When to remove it?

A
  • MOST of the time its S. Aureus
  • Remove: SUBQ tunnel infection, cant clear in 72h, still has fever, septic emboli
  • REMOVE cath –> 14d of AMP B or Fluconazole to prevent disseminated candidiasis
25
Q

What is the most important determinant of Patient outcomes>

A
  • Resolution of neutropeina

PHRM 865: Theraputics V (42 decks)

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