neutropenic fever

Question 1

define febrile neutropenia

Answer 1

sustained fever off over 38.3 C with a neutrophil count of less than 500 cells/ml or expected to decrease to that level within the next 48 hours

Question 2

most common organisms associated with febrile neutropenia

Answer 2

gram positive organisms

Question 3

what investigations should be performed in suspected neutropenic fever include

Answer 3

Two blood cultures taken simultaneously form 2 peripheral venepunctures or one peripheral and any central venous access

radiological diagnostic must also bee applied based on the suspected site of infection

respiratory signs ? chest x-ray or CT

Question 4

what is used to asses the risk index in neutropenic fever

Answer 4

MASCC score
anything above 21 are at low risk of complications whilst anything above 21 is at high risk of complications

Question 5

what is the management of neutropenic fever

Answer 5

1- after identification of a fever on 2 readings of higher than 38.4 and an ANC of 500 or less

2- MASCC score should bee calculated ( over 21 is considered high risk )

3- high risk patients should be admitted to the hospital and started on IV antibiotics
4- low risk patients ( MASCC score of less than 21) should be discharged to outpatient and sent with an oral antibiotic

Question 6

who are the low risk patients ?

Answer 6

have a score of under 21 on the MASCC scoring system
have neutropenia that is expected to resolve within 7 days
usually associated with patients that have solid tumors

Question 7

what are the indications regarding antibiotic use in low risk patients

Answer 7

oral quinolone to be avoided if quinolone was previously taken as prophylaxis

Question 8

who are the high risk patients

Answer 8

those with a MASCC score of less than 21
neutropenia of less than 100 and not expected to resolve within 7 days
presence of comorbidities
evidence of hepatic or renal impairment

Question 9

in cases of high risk neutropenic fever -standard treatment for gram negative bacteria and MRSA ?

Answer 9

carbapenem
cephalosporin

Question 10

in cases of high risk neutropenic fever - clinically unstable/septic shock/ respiratory distress/ Hx of pseudomans infection

Answer 10

anti pseudomonal beta lactam along with an aminoglycoside

Question 11

in cases of high risk neutropenic fever
gram positive/ catheter related infections / resistant to penicillin/ hypotension or shock

Answer 11

vancomycin
teicoplanin is an alternative

Question 12

in cases of high risk neutropenic fever - vancomycin resistant infection

Answer 12

linezolid

Question 13

how can catheter related bacteremia be confirmed or highly suspected ?

Answer 13

blood must be cultured from both thee catheter and peripherally to measure DTTP
DTTP of more than 2 hours is highly indicative of catheter related bacteraemia

Question 14

if pneumonia, pneumocystis infection or cellulitis is diagnosed on clinical grounds ?

Answer 14

pneumonia - adding a macrolide to a beta lactam antibiotic
pneumocystis infection - high dose co-trimoxazole
cellulitis - add vancomycin

Question 15

management in clinical or microbiological evidence of intra-abdominal or pelvic sepsis

Answer 15

add metronidazole
assessment for clostridium is necessary

Question 16

management in cases of vesicular lesions or suspected viral infections

Answer 16

therapy with acyclovir
ganciclovir only to be used in high suspicion of CMV

Question 17

management in suspected meningitis or encephalitis ?

Answer 17

lumbar puncture is mandatory
bacterial meningitis - ceftazidime + ampicillin
viral encephalitis - acyclovir

Question 18

which patients are at risk of candidiasis ?

Answer 18

prolonged neutropenia
those with haematological malignancies undergoing myeloablative therapy

Question 19

when is treatment of candidiasis indicated and what is the treatment of candidiasis in neutropenic fever ?

Answer 19

indication : empirical treatment in patients whose fever fail to respond to broad spectrum antibiotics after 3-7 days

already exposed to an azole ?
give liposomal amphotericin B or caspofungin

low risk of invasive aspergillosis ?
fluconazole

Question 20

role of GCSF

Answer 20

granulocyte colony stimulating factor
should be used in high risk patients
recommended in moderate risk
not used in low risk patients

Question 21

when should MGF be used ?

Answer 21

in cases of radiation induced myelosuppression

Question 22

how should GCSF be used ?

Answer 22

if received it as prophylaxis then continue until recovery
if received long acting - nothing more
didn’t receive prophylaxis ? daily GCSF until normal count
no high risk features ? no need for GCSF

Question 23

when should follow up for neutropenic fever patients bee

Answer 23

48 hours after initiation of treatment

Question 24

what is the next best step in mngmnt after 48 hours of therapy and fever has improved and ANC has risen above 500

Answer 24

identify if thee patient is low or high risk first
low risk - continue oral ab and early dischargee
high risk - if there is an identified pathogen give specific ab therapy
no pathogen then discontinue aminoglycosidde and continue IIV therapy

Question 25

what is the best next step in mngmnt of a patient that still has a fever after 48 hours of therapy

Answer 25

asses if the patient is stable or not first
stable ? continue therapy
unstable - hospital admission