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444-Oncology and Neurology > Myelosuppression, febrile neutropenia, and cancer related infection considerations > Flashcards

Myelosuppression, febrile neutropenia, and cancer related infection considerations Flashcards

1
Q

what is myelosuppression

A

reduced activity of bone marrow = less RBCs, WBCs, platelets
is a common SE is the dose limiting toxicity of chemo

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2
Q

what is myeloablation

A

severe myelosuppression difficult to overcome without a stem cell infusion

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3
Q

neutrophil lifespan

A

8hrs

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4
Q

neutrophil purpose

A

kill bacteria using enzyme rich granules through endocytosis or phagocytosis

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5
Q

implications if neutropenia

A

increased risk of severe infections

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6
Q

erythrocyte lifespan

A

120 days

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7
Q

low erythrocyte sx

A

fatigue, SOB

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8
Q

thrombocyte lifespan

A

5-10d

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9
Q

thrombocyte fxnn

A

are platelets- essential for clotting

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10
Q

thrombocytopenia sx

A

bleed

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11
Q

T or F: anemia from myelosuppression may be prevented with iron, folate, or B12

A

F- is caused by bone marrow damage, not lack of things

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12
Q

if a pt on severely myelosuppressive chemo has severe anemia, what do

A

blood transfusion

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13
Q

reduced platelets may result in bruising, bleeding, and _________

A

petechiae type rash

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14
Q

Depending on antineoplastic regimen, treatment delay or dosing may be adjusted if platelets are <____x109/L

A

50-100

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15
Q

If platelets are critically low (<10x109/L) on chemo, pt may be given a ______

A

platelet transfusion

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16
Q

pt education on thrombocytopenia

A

awareness of easier bruising
soft toothbrush
blow nose gently
avoid constipation and straining
avoid/ caution with NSAIDs
medical attention required if uncontrolled bleed

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17
Q

3 considerations for cancer related infections

A
  1. immune function in cancer pt
  2. infection portals in cancer pts
  3. microbiology in cancer pt’s own flora
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18
Q

what disease factors can affect immune function in cancer pts

A

impaired humoral immunity (myeloma = less antibodies) and cell mediated immunity (T cell lymphoma = T cells not functional)

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19
Q

what are tx factors that can affect immune function in cancer pts

A

chemo induced neutropenia
immunosuppressants like corticosteroids, prednisone
radiation therapy

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20
Q

describe chemo induced neutropenia

A

Good cells impacted by cytotoxic drugs, including the neutrophils produced in the bone marrow
Neutrophil count will begin to fall ~5-12d after chemo (depending on regimen)
Dose related

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21
Q

what is NADIR

A

when neutrophils are at their lowest number in circulating blood
the higher the chemo dose, the lower the NADIR

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22
Q

what are some infection portals in cancer pts

A

environmental exposure (airborne, droplet, ingestion)
damage to skin (catheters, antineoplastic AEs, surgical wounds)
damage to mucosal membranes (oral mucositis, gastric mucositis, rectal issues)
medical procedures like endoscopy and bronchoscopy

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23
Q

what is bacteremia

A

bacteria in the bloodstream

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24
Q

what gram is more common in bacteremia? which is associated with higher morality

A

gram + more common
gram - higher mortality

25
Q

in pts who are neutropenic, what happens in an infection?

A

s/s may eb absent or altered due to low number of WBCs = can’t mount a norml immune response
some pts show no signs other than a fever

26
Q

a fever in a neutropenic cancer pt is _______

A

assumed to be an infection until proven otherwise- is an oncologic emergency

27
Q

skin flora is usully

A

gram +

28
Q

what is neutropehnai

A

Reduced # of neutrophils in peripheral blood

29
Q

infection concern is heightened when neutrophil is ______ or less

A

0.5x10^9/L or less

30
Q

what is febrile neutropenia (temps, neutrophil count)

A

Single oral temp ≥38.3 or sustained temp ≥38.0 for >1hr
ANC <0.5x109/L or expected to fall to <0.5x109/L within the next 48hrs
Is an oncologic medial emergency- high morality, infection progress rapidly + life threatening quickly + prompt, empiric abx reduced mortality

31
Q

pt workup with culture and sensitivities in febrile neutropenia should include

A

2 sets of blood- peripheral and central access (do ASAP before tx)
Test other possible sites of infection as indicated

32
Q

T or F: in FN, you should wait for lab resutls before initiating tx

A

F- start broad spectrum abx asap after culture results

33
Q

how does the MASCC cancer risk index score work?

A

lower the score = higher risk

34
Q

what are some features of high risk of complications/ death in FN pts

A

Prolonged (>7d) or profound (<0.1x109/L) neutropenia
Consider pt disease and chemo received
Unstable (hypotension, neuro changes, new onset abd sx, high fever)
Significant med/ comorbid conditions (pneumonia, COPD, mucositis)
Worrisome infection (or sus infection) and/or symptomatic (high fever, neuro changes)
Pneumonia, bacteremia, SSTI
Difficult access to urgent care

35
Q

what are some features of low risk of complications/ death in FN pts

A

No focal findings of infx, hemodynamically and clinically stable
Brief neutropenic period (<7d)
No or few comorbidities
No focal source of infection + asymptomatic
Easy access to urgent care + able to take PO meds

36
Q

how to treat high risk pts with FN

A

admit + start IV empiric therapy ASAP

37
Q

how to treat low risk pts with FN

A

start tx with oral or IV in clinic/ hospital, then consider outpt (PO or home parenteral therapy program)

38
Q

when should you start empiric antimicrobial therapy in FN

A

immediately after cultures

39
Q

what kind of spectrum should empiric antibiotics in FN cover

A

gram - (including pseudomonas)
gram + (if MRSA risk)
usually anaerobes

40
Q

what should be started for empiric broad spectrum in high risk FN pts

A

monotherapy with antipseudomonal beta lactams like piptazo, cefepime, carbapenem
add gram + coverage if risk of MRSA
then use cultures to target tx (48-72hrs to process)

41
Q

what should be started for empiric broad spectrum in low risk FN pts

A

monotherapy with antipseudomonal beta lactams like piptazo, cefepime, carbapenem
add gram + coverage if risk of MRSA
then use cultures to target tx (48-72hrs to process)

above is same as high risk
- but could use oral ciprofloxacin + amoxi/clav if they can tolerate it
- also avoid ciprofloxacin if recieving quinolone prophylaxis

42
Q

what is the usual length of therapy with abx in FN if stable and no source of fever identified + what about for high risk pts

A

treat until febrile for =>2d and neutrophils are >0.5 and trending up
usually minimum 7 day course for high risk pts + longer if mucositis

43
Q

what is FN prophylaxis

A

G-CSF with filgrastim or PEG-filgrastim to accelerate neutrophil recovery after chemo

44
Q

AEs fo filgrastim

A

bone pain- tx with tylenol

45
Q

pros of FN prophylaxis

A

less risk of FN, infection related + all cause mortality, improved intensity of chemo

46
Q

cons of FN prophylaxis

A

costly, AEs, SQ admin of ambulatory pts

47
Q

what is primary FN prophylaxis

A

Using CSFs to prevent FN with first cycle of tx + continuing with subseq cycles
Recommended for pts with ≥20% risk of FN

48
Q

what is secondary FN prophylaxis

A

If pt gets FN without 1o prophylaxis = can reduce chemo dose/ delay next cycle
2o: starting prophylaxis after an episode of FN
Recommended for those who exp a neutropenic comp from prev chemo AND dose reduction/ tx delay can comp outcomes (disease free/ overall survival)

49
Q

FN prophylaxis with antibiotics is done with ______ for _____________

A

quinolones (cipro or levofloxacin) for high risk pts expected to have prolonged/ profound neutropenia

50
Q

what type of thermometer should be avoided in FN

A

rectal- infection + bleed risk

51
Q

T or F: annual influenza vaccine is fine for most adults with cancer

A

T

52
Q

what cancer pts should avoid influenza vaccines (3)

A
  • those on rituximab or other B cell depleting abx
  • CTLA4i
  • high dose systemic steroids
53
Q

how long should rituximab/ B cell depleting therapies wait before getting annual influenza

A

6mths after last dose

54
Q

how long should CTLA4i pts wait until getting annual influenza

A

6mths

55
Q

how long should pts on high dose systemic steroids wait before annual influenza

A

4wks

56
Q

how long after stem cell transplant can you get a nonlive vaccine? what about live?

A

6mths
2yrs for live

57
Q

how long does it take for your immune system to recover after a stem cell transplant

A

6-24mths

58
Q

how long after stem cell transplant can you get the covid vaccine

A

4mths

444-Oncology and Neurology (22 decks)

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