Myelosuppression, febrile neutropenia, and cancer related infection considerations Flashcards
what is myelosuppression
reduced activity of bone marrow = less RBCs, WBCs, platelets
is a common SE is the dose limiting toxicity of chemo
what is myeloablation
severe myelosuppression difficult to overcome without a stem cell infusion
neutrophil lifespan
8hrs
neutrophil purpose
kill bacteria using enzyme rich granules through endocytosis or phagocytosis
implications if neutropenia
increased risk of severe infections
erythrocyte lifespan
120 days
low erythrocyte sx
fatigue, SOB
thrombocyte lifespan
5-10d
thrombocyte fxnn
are platelets- essential for clotting
thrombocytopenia sx
bleed
T or F: anemia from myelosuppression may be prevented with iron, folate, or B12
F- is caused by bone marrow damage, not lack of things
if a pt on severely myelosuppressive chemo has severe anemia, what do
blood transfusion
reduced platelets may result in bruising, bleeding, and _________
petechiae type rash
Depending on antineoplastic regimen, treatment delay or dosing may be adjusted if platelets are <____x109/L
50-100
If platelets are critically low (<10x109/L) on chemo, pt may be given a ______
platelet transfusion
pt education on thrombocytopenia
awareness of easier bruising
soft toothbrush
blow nose gently
avoid constipation and straining
avoid/ caution with NSAIDs
medical attention required if uncontrolled bleed
3 considerations for cancer related infections
- immune function in cancer pt
- infection portals in cancer pts
- microbiology in cancer pt’s own flora
what disease factors can affect immune function in cancer pts
impaired humoral immunity (myeloma = less antibodies) and cell mediated immunity (T cell lymphoma = T cells not functional)
what are tx factors that can affect immune function in cancer pts
chemo induced neutropenia
immunosuppressants like corticosteroids, prednisone
radiation therapy
describe chemo induced neutropenia
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
what is NADIR
when neutrophils are at their lowest number in circulating blood
the higher the chemo dose, the lower the NADIR
what are some infection portals in cancer pts
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
what is bacteremia
bacteria in the bloodstream
what gram is more common in bacteremia? which is associated with higher morality
gram + more common
gram - higher mortality
in pts who are neutropenic, what happens in an infection?
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
a fever in a neutropenic cancer pt is _______
assumed to be an infection until proven otherwise- is an oncologic emergency
skin flora is usully
gram +
what is neutropehnai
Reduced # of neutrophils in peripheral blood
infection concern is heightened when neutrophil is ______ or less
0.5x10^9/L or less
what is febrile neutropenia (temps, neutrophil count)
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
pt workup with culture and sensitivities in febrile neutropenia should include
2 sets of blood- peripheral and central access (do ASAP before tx)
Test other possible sites of infection as indicated
T or F: in FN, you should wait for lab resutls before initiating tx
F- start broad spectrum abx asap after culture results
how does the MASCC cancer risk index score work?
lower the score = higher risk
what are some features of high risk of complications/ death in FN pts
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
what are some features of low risk of complications/ death in FN pts
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
how to treat high risk pts with FN
admit + start IV empiric therapy ASAP
how to treat low risk pts with FN
start tx with oral or IV in clinic/ hospital, then consider outpt (PO or home parenteral therapy program)
when should you start empiric antimicrobial therapy in FN
immediately after cultures
what kind of spectrum should empiric antibiotics in FN cover
gram - (including pseudomonas)
gram + (if MRSA risk)
usually anaerobes
what should be started for empiric broad spectrum in high risk FN pts
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)
what should be started for empiric broad spectrum in low risk FN pts
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
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
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
what is FN prophylaxis
G-CSF with filgrastim or PEG-filgrastim to accelerate neutrophil recovery after chemo
AEs fo filgrastim
bone pain- tx with tylenol
pros of FN prophylaxis
less risk of FN, infection related + all cause mortality, improved intensity of chemo
cons of FN prophylaxis
costly, AEs, SQ admin of ambulatory pts
what is primary FN prophylaxis
Using CSFs to prevent FN with first cycle of tx + continuing with subseq cycles
Recommended for pts with ≥20% risk of FN
what is secondary FN prophylaxis
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)
FN prophylaxis with antibiotics is done with ______ for _____________
quinolones (cipro or levofloxacin) for high risk pts expected to have prolonged/ profound neutropenia
what type of thermometer should be avoided in FN
rectal- infection + bleed risk
T or F: annual influenza vaccine is fine for most adults with cancer
T
what cancer pts should avoid influenza vaccines (3)
- those on rituximab or other B cell depleting abx
- CTLA4i
- high dose systemic steroids
how long should rituximab/ B cell depleting therapies wait before getting annual influenza
6mths after last dose
how long should CTLA4i pts wait until getting annual influenza
6mths
how long should pts on high dose systemic steroids wait before annual influenza
4wks
how long after stem cell transplant can you get a nonlive vaccine? what about live?
6mths
2yrs for live
how long does it take for your immune system to recover after a stem cell transplant
6-24mths
how long after stem cell transplant can you get the covid vaccine
4mths
