Lecture 29: Immuncomp Host Flashcards
What is the definition of someone that has Neutropenia?
- 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
What are some of the common pathogens in Neutropenia?
Bacteria? Fungi? Virus?
- Bacteria: S. Aureus, S. Epidermidis, Strep, Entercocci, Enterobacterales, P. Aeruginose
- Fungi: Candida, Aspergillus, Mucor, Rhizopus
- Viruses: HSV
What are some of the Immune System Defects that can happen to someone that has Neutropenia?
T-cells? B-cells?
- 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]
What are some of the way that destruction of Protective barriers can have an effect on Neutropenia?
Skin? Mucus Membrane? Surgery?
- 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]
What is the Epidemiology of infections in Neutropenic Cancer Patients?
- 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
What is the etiology for infections in Neutropenic Cancer Patient?
- S. Aureus [MRSA]
- Virdians [b-lactam resistant??]
- Enterbacterales [E. Coli and Kleb the most common]
- P. Aeruginosa
- VRE, Lactobacillus, Strentrophomonas
What are the two most common Invasive Fungal Infections in Neutropenia?
- Candida Albacins [most common - may get into the throat, blood, organs]
- Apsergillus [from inhalation,Prolonged Neutropenia is a major risk factor]
What is important to know about the Herpes Simplex Virues in Neutropenia?
- Mainly in those that have had herps
- Untreated may go to esophagus
What is important to know about Pneumocystis Jirovecii & Toxoplasma Gondii in Neutropenia?
- Routine Prophylaxis with Bactrim is good
What are some of the Clinical Presentations for someone with neutropenia?
- FEVER; the most important [maybe only]
What are some fo teh Labs and Diagnostic Test that should be done for someone with neutropenia?
- Blood cultures [at least 2 sets; multi-line = get from all]
- CBC
- CXR
What are some of the goals of antimircobial therapy for those managing febrile episodes of neutropenia?
- Prvent death?? [duh]
- Prevent breakthrough
- Treat infection
- Reduce Morbidity
- Stewardship
What does it mean when a patient is low risk after finding out if they have a Fever and are Neutropenic?
- Neutropenia < 7d, stable, no comorbidites, outpatient fever onset
For the Low Risk Neutropenic Patient, what is the treatment for adequate outpatient infrastructure?
- PO Levo or Cipro + Augmentin; Then
- Observe for 24h –> still stabe then send home
For the Low Risk Neutropenic Patient, what is the treatment for Inadequate outpatient infrastructure?
- Inpatient IV [Pip/tazo, Cefepime, Ceftazidime, Mero, Imip]; then
- Step down when good [no fever for < 72h, (-) cultures, PO meds]
What does it mean when a patient is high risk after finding out if they have a Fever and are Neutropenic?
- Neutropenia > 7d, unstable, comorbidites, inpatient fever onset
MASCC < 21
For the High Risk Neutropenic Patient, what is the treatment?
- Inpatient IV [Pip/Tazo, Mero, Imip, Cefepime, Ceftazidime]; then
- (+) IV Vacnomycin [for cellulitis, pnumonia, severe sepsis, MRSA…]; OR
- (+) AG or Levo/Cirpo [Gram (-)]
What is the Empiric Antibiotic Regimens: b-lactam monotherapy for the empiric treatment of Febrile Neutropenia?
Advantages? Disadvantages?
- 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
What is the Empiric Antibiotic Regimens: Addition of Vancomycin to antipseudomonal b-lactam for the empiric treatment of Febrile Neutropenia?
- NOT recommended Vancomycin or other gram (+) agents as part of the INITIAL regimen
What is the Empiric Antibiotic Regimens: Penicillin-allergic patients for the empiric treatment of Febrile Neutropenia?
- AVOID b-lactams & carbapenems in history of hypersensitivity
- Cipro + Aztreonam + Vancomycin
What is some of the management of antimicrobial therapy after the start of empiric therapy?
MRSA? VRA? ESBL? KPC?
- 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
What should you do for the initiation of antufungal treatment and what are some of the treatment options?
-
- 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
What should you do for the initiation of antiviral treatment and what are some of the treatment options?
- Start aggressive therpay to help with healing and prevent dissemination
- HSV, VZV: Acyclovir [or Valacyclovir]
- CMV: Ganciclovir [or Valganciclovir]
What is important to note about Catheter-Related Bacteremia?
what is the pathogen? When to remove it?
- 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
What is the most important determinant of Patient outcomes>
- Resolution of neutropeina
