neutropenia Flashcards
what is neutropenia?
NEUTROPENIA:
o ANC <100
What is neutropenic fever?
Neutropenic fever = single oral temp >38.1 or >38.0 for 1 hour with ANC <500 within 48h
Who is considered high risk?
Most experts consider high-risk patients to be those with anticipated prolonged (>7 days
duration) and profound neutropenia (absolute neutrophil count [ANC] ≤100 cells/mm3
following cytotoxic chemotherapy) and/or significant medical co-morbid conditions, including
hypotension, pneumonia, new-onset abdominal pain, or neurologic changes. Such patients
should be initially admitted to the hospital for empirical therapy (A-II).
Who is considered low risk?
Low-risk patients, including those with anticipated brief (≤7 days duration) neutropenic periods
or no or few co-morbidities, are candidates for oral empirical therapy
what is the initial lab tests to order?
(CBC) count with differential
leukocyte count and platelet count; BUN/Cr, electrolytes, LFT’s , and total bilirubin. two sets of blood cx (2 from periph, 2 from port)
What abx do you give high risk pts?
monotherapy with an anti-pseudomonal β-lactam agent, such as cefepime, a carbapenem (meropenem or imipenem-cilastatin), or piperacillin-tazobactam, is recommended
Is Vanco given first line for high risk pts?
No, but you can add if you suspect catheter-related infection, skin or soft-tissue infection, pneumonia, or hemodynamic instability.
What abx do you add to empiric therapy and when
(aminoglycosides, fluoroquinolones, and/or vancomycin) when you have hypotension or pna or suspect resistance
What abx do you add to empiric therapy if you suspect MRSA?
vancomycin, linezolid, or daptomycin
What abx do you add to empiric therapy if you suspect VRE
linezolid or daptomycin
What abx do you add to empiric therapy if you suspect ESBL
carbapenam
What abx do you add to empiric therapy if you suspect KPC
polymyxin-colistin or tigecycline
What do you give to true pcn allergic
ciprofloxacin plus clindamycin
or aztreonam plus vancomycin
What is empiric abx for low risk pt?
Ciprofloxacin plus amoxicillin-clavulanate
should you change abx if persistant fever?
Unexplained persistent fever in a patient whose condition is otherwise stable rarely
requires an empirical change to the initial antibiotic regimen. If an infection is identified,
antibiotics should be adjusted accordingly
if Vanco was started but then cx were negative, when do you stop?
If vancomycin or other coverage for gram-positive organisms was started initially, it may
be stopped after 2 days if there is no evidence for a gram-positive infection
when do you switch from IV to oral abx?
An IV-to-oral switch in antibiotic regimen may be made if patients are clinically stable and
gastrointestinal absorption is felt to be adequate
When should you give antifungal?
Empirical antifungal coverage should be considered in high-risk patients who have
persistent fever after 4–7 days of a broad-spectrum antibacterial regimen and no identified
fever source
How long to give abx if documented infection?
the duration of therapy is dictated by the particular organism and site; appropriate antibiotics should continue or at least the duration of neutropenia (until ANC is ≥ 500 cells/mm3) or longer if clinically necessary
How long do you give abx if there is no fever source?
In patients with unexplained fever, it is recommended that the initial regimen be continued
until there are clear signs of marrow recovery; the traditional endpoint is an increasing ANC that
exceeds 500 cells/mm3
When do you give prophylaxis.
in high risk pt:Fluoroquinolone prophylaxis should be considered for high-risk patients with expected
durations of prolonged and profound neutropenia (ANC ≤100 cells/mm3for >7 days) (B-I).cipro/levaquin. don’t give to low risk
Do you recommend flu vaccine and when ?
Yes, Optimal timing of vaccination is not established, but serologic responses may be best between chemotherapy cycles (>7 days after the last treatment) or >2 weeks before chemotherapy starts
Do you give CSF for neutropenic fever?
CSFs are NOT generally recommended for treatment of established fever
and neutropenia
Do you pull the catheter for central line associated blood stream infections
For CLABSI caused by S. aureus, P. aeruginosa, fungi, or mycobacteria, catheter removal
is recommended in addition to systemic antimicrobial therapy for at least 14 days (A-II).
Catheter removal is also recommended for tunnel infection or port pocket site infection, septic
thrombosis, endocarditis, sepsis with hemodynamic instability, or bloodstream infection that
persists despite ≥72 h of therapy with appropriate antibiotics. you can maintain if coag neg staph
What is the MASCC score
Low Risk = score >=21
High Risk <21
Feature Points
Burden of febrile neutropenia with no or mild symptoms 5
No hypotension (SBP>90 mmHg) 5
No COPD symptoms 4
Solid tumor w no previous fungal infection 4
No dehydration requiring IVF 3
Burdent of febrile neutropenia w moderate symptoms 3
Outpatient status 3
Age <21 = HIGH RISK
