Mar26 M1-Febrile Neutropenia

Question 1

febrile neutropenia occurs in what patients usually

Answer 1

cancer pts on chemo

Question 2

pathophysiology of febneut

Answer 2

1. chemo and anti-cancer drugs damaging to rapidly proliferating cell lines (BM, GIT)
2. GIT mucosa acting as bacteria barrier is impaired = bacteria and fungi get in blood
3. low neutrophils (needed to fight infection) bc of drop of cell prod in BM

Question 3

only sign of inflammation in pt on chemo with febneut

Answer 3

fever. no pus, inflam response is diminished bc low neutrophils

Question 4

treatment of feb neut

Answer 4

-empiric systemic Abx immediately

febneut = medical emergency

Question 5

how helpful physical exam is to find cause of fever in febneut

Answer 5

not helpful, often won’t find cause of fever on physical exam

Question 6

how neutrophils drop with time in feb neut and with every chemo round

Answer 6

drop until reach a naiter point (lowest point) (bc every chemo round has an element of BM suppression)

Question 7

when Abx stopped in febneut

Answer 7

once neutrophils over 500 for 2 consecutive days

Question 8

definition of febrile neutropenia

Answer 8

1. oral temp over 38.3 (or between 38 and 38.2 for an hour)
   axillary = add 0.5
   don’t do rectal in neutropenic

Question 9

neutropenia definition

Answer 9

• lower than the normal 1.8 to 7.5
• usually use <1.5
• severe = less than 500
• myelodysplastic syndrome (normal nbr but abnormal fct) = neutropenia too

Question 10

pathogenesis of febneut: what chemo does

Answer 10

• mucositis (radiation and chemo cause DNA damage and release of inflam cytokines)
• often oral mucositis = consider it’s in whole GIT

Question 11

type of bacteria we’re afraid of in febneut (we don’t want them to be in circulation)

Answer 11

gram negatives

Question 12

causes of febneut other than the chemotherapy

Answer 12

immune defects in general

1. (anti cancer tx attakc BM)
2. myelodysplastic syndromes
3. splenectomy
4. CLL
5. immunosuppression (glucocorticoids, HIV)

Question 13

3 types of risk factors for complications in febneut

Answer 13

1. patient related predictors (>65, poor feeding, active comorbidities)
2. disease related predictors (advance stage of cancer, BM failure bc marrow involved)
3. anti-cancer tx related predictors (high dose chemo, absence of GF support)

Question 14

risk stratification in febneut patients: how it’s done

Answer 14

1. high risk = expected to have <100 for over 7 days. will include neut<500, IV Abx, often prolonged. + include pt with transplant or AML
2. low risk = anc (absolute neutrophil count) < 500 expected for less than 7 days + no other problems. can receive Abx as outpatient + include pt with solid tumor

Question 15

infectious vs non-infectious causes os febneut + when give Abx

Answer 15

• infectious = often endogenous bacteria from gut flora
• non-infectious = drug, transfusion rx, rash, underlying cancer
• ALWAYS give Abx

Question 16

most common pathogens seen today as cause of febneut

Answer 16

• G+ bacteria

- MOST COMMON IS STAPH EPIDERMIS: very virulent

Question 17

some common cultured organisms in febneut

Answer 17

-G- like pseudomonas, e.coli
-G+ like staph epidermis, staph
aureus
-fungi
-herpes

Question 18

when to consider fungi as cause of febneut

Answer 18

• persistent fever or fever that stops and comes back + neutrophils that are low for over 2 weeks
• *fever that respikes = treat for fungi

Question 19

viruses that reactivate in febneut

Answer 19

• HSV
• HSZ
• CMV, EBV, HHV-8
• respiratory viruses (infleunza, RSV, adenovirus, metapneumovirus)

Question 20

steps when see pt with febneut

Answer 20

1. vitals
2. IV access
3. draw blood to check neutropenia
4. CBC, fever, status, electrolytes
5. blood cultures
6. Abx
7. CXR and other

Question 21

things to check on physical exam (the important stuff)

Answer 21

• check impaired mental status (may indicate sepsis and incoming shock)
• vitals
• infected mucosas = sinuses, mucous membranes, gingiva, teeth, lungs, abdoment (bloating, tenderness, perit signs, hemorrhoids)
• no rectal exam*

Question 22

typical physical exam sign in G- infections like pseudomonas

Answer 22

primary ecthyma gangrenosum (erythema + dark center)

Question 23

medication to avoid in febneut

Answer 23

tylenol or NSAIDs (because masks the fever and then no way of following disease)

Question 24

main management goals in febneut

Answer 24

• empiric Abx (cover the most virulent pathogens like G- pseudomonas)
• always cover most virulent even if see signs of G+ for ex (like skin lesions)
• start Abx immediately

Question 25

high risk patients management

Answer 25

• initiate monotherapy with anti-pseudomonal beta lactam Abx
• meropenem and piperacillin-tazobactam
• anti-fungals at 4 days if cause of fever not found
• NO G+ coverage initially (only if sepsis, pneumonia, bad CV disease, etc.)
• anaerobic coverage only if sinusitis, periodontal cellulitis, necrotizing mucositis, etc.

Question 26

most common G+ organisms Abx

Answer 26

vancomycin

Question 27

most common anaerobes coverage Abx

Answer 27

metronidazole (Flagyl)

Question 28

when to stop febneut therapy

Answer 28

ANC>500 + afebrile, all that for 2 days

Question 29

low risk pts management

Answer 29

• IV Abx as outpatient and stay close

- readmit if fever worsens, persists, new symptoms and signs of infection

Question 30

normal regimen for low risk pts in febneut

Answer 30

1. ciproflaxin (fluoroquinolone = broad spectrum + only p.o. against pseudomonas)
2. clavulin (beta-lactam = G+, G-, anaeorbes, NOT pseudomonas)