Neutropenic fever

Question 1

cause of fever in most neutropenic fever patients

Answer 1

endogenous microflora

Question 2

medication associated with reaction of HSV and VZV

Answer 2

mTOR inhibitors (sirolimus, everolimus)

Question 3

when ANC is expected to reach nadir with chemo treatment

Answer 3

12 to 14 days from day 1

Question 4

cancer type in which neutropenic fever is most common

Answer 4

acute leukemia, substantially less common in solid organ

Question 5

most frequent pathogens in neutropenic fever

Answer 5

gram-positive bacteria (anaerobes infrequent)

Question 6

what is the term for G-CSF and GM-CSF agents?

Answer 6

colony stimulating factors

Question 7

what is myeloid reconstitution syndrome?

Answer 7

Onset or progression of an inflammatory focus defined clinically or radiologically temporally related to neutrophil recovery.

Question 8

evidence for antibiotic prophylaxis for high risk neutropenic patients?

Answer 8

Effective but high NNT, and there are a lot of downsides (cost, side effects, resistance), so should be limited to high risk patients.

Question 9

risk of fungal infection?

Answer 9

Very low among patients for whom the anticipated duration of neutropenia (ANC <500 cells/microL) is anticipated to be seven days or fewer.

Question 10

when risk of neutropenia is highest during chemo

Answer 10

typically during the first two cycles of chemotherapy

Question 11

RF’s for neutropenic events

Answer 11

• age >65 years
• preexisting neutropenia or extensive bone marrow involvement by tumor
• more advanced cancer
• poor performance and/or nutritional status - renal or hepatic dysfunction

Question 12

Guideline update on use of colony stimulating factors during COVID-19

Answer 12

NCCN and ASCO have lowered the threshold for the use of myeloid growth factors from those chemotherapy regimens which have a 20 percent or higher risk of febrile neutropenia to now include those regimens with a risk of 10 to 20 percent, which includes all of the intermediate-risk chemotherapy regimens.

Question 13

General term for medications used to

Answer 13

Colony stimulating factors

Question 14

Why don’t we use CSF’s to treat neutropenic fever?

Answer 14

1) Controversial and mixed results. (no effect on mortality, shorter hospital stays in studies, but also increased rates of side effects).
2) It takes several days for CSF to produce a response with increased circulating neutrophils, so antibiotics work faster.

Question 15

Neupogen generic name

Answer 15

Filgrastim

Question 16

neulasta generic name

Answer 16

Pegfilgrastim

Question 17

optimal duration of GCSF per guidelines

Answer 17

No consensus, guidelines vary
NCCN guidelines suggest daily administration until the post-nadir ANC recovers to normal or near-normal levels by laboratory standards

Question 18

Why neulasta is typically used

Answer 18

Multiple RCTs and a meta-analysis have shown that pegfilgrastim is at least as effective as and more convenient to administer than G-CSF for primary prophylaxis in patients requiring CSF treatment during myelosuppressive chemotherapy

Question 19

Potential treatment side effect of CSFs

Answer 19

therapy related myeloid neoplasm (a small but real increased risk of therapy-related myeloid neoplasms (myeloid growth factor receptors are expressed by several hematopoietic and nonhematopoietic cell types)

Question 20

Risk of complications in neutropenic fever is based on…

Answer 20

duration and severity of neutropenia

Question 21

When do you modify initial antibiotic regimen?

Answer 21

IF fever persists after 4 days → add antifungal coverage
Positive infectious workup
Hemodynamic instability
*NOT for persistent with negative workup

Question 22

when people are at increased risk of fungal infections

Answer 22

• prolonged duration of neutropenia (more than 7 days of persistent neutropenia)

- comorbidities

Question 23

how long do you continue abx?

Answer 23

Discontinue once myeloid reconstitution (ANC>500) + afebrile x48h

Question 24

Evidence for use of CSF’s in neutropenic fever

Answer 24

NOT recommended

Question 25

Median time to deferfescence

Answer 25

• 5 days (in contrast to 2 for solid tumors)

* ***so patients take longer to deferfesce (antibiotic may be covering infection but delay in response)

Question 26

IFI means…

Answer 26

invasive fungal infection

Question 27

Fungitell tests for

Answer 27

b-d-glucan, which is present in a wide variety of fungal pathogens (candida, aspergillus, pneumocystis)

Question 28

Galactomannan tests for

Answer 28

Aspergillus (important cell wall component)

Question 29

Definition of neutropenic fever

Answer 29

• single fever + ANC less than 500

Question 30

outpatient abx for neutropenic fever

Answer 30

Cipro + augmentin

Question 31

Initial therapy for inpatient management of neutropenic fever

Answer 31

Anti-pseudomonal beta-lactam (Cefepime or zosyn)

Question 32

Indications for adding gram-positive coverage

Answer 32

• suspected line sepsis
• hemodynamic instability
• skin infections

Question 33

ANC cutoff defining neutropenic fever

Answer 33

1000

Question 34

Fever definition

Answer 34

38.3 single oral temp or 100.4 for 1 hr

Question 35

2 most impt variables determining high risk neutropenia

Answer 35

• duration

- comorbidities

Question 36

Decision support tools guiding inpatient vs outpatient management

Answer 36

MASCC (liquid tumor) and CISNE (solid tumor)

Question 37

outpatient abx for neutropenic fever

Answer 37

cipro + augmentin (gram positive coverage)

Question 38

initial abx options

Answer 38

cefepime, zosyn, meropenem

Question 39

IDSA time window for abx for high risk febrile neutropenia

Answer 39

within 1 hr

Question 40

when are people generally speaking at risk for fungal infections?

Answer 40

prolonged neutropenia

Question 41

most common fungus in myeloid malignancy patients with prolonged neutropenia?

Answer 41

aspergillus

Question 42

Mold active azoles

Answer 42

posa, vori, isavuconazole

Question 43

know regimens with 20% or higher risk of febrile neutropenia

Answer 43

(think about each cancer subtype)
ddMVAC
dose dense AC
FOLFOXIRI
TPF
EPOCH
Hyper-CVAD
Topotecan
others (look at NCCN)