Neutropenic Fever- Schoenwald Flashcards
Neutropenic fever is defined as a fever in the setting of _________ & active ___________
cancer, active chemotherapy
Neutropenic fever is usually caused by colonizing _________ or __________ of the _________
bacteria, yeast, GI tract
Chemo can disrupt the mucous membranes of the mouth and GI tract allowing for organisms to enter
Chemo suppresses the ___________ system and also __________
the immune system and bone marrow
Also neutropenic so less neutrophils to fight infection
What is the fever criteria for neutropenic fever?
A fever >101 OR fever of 100.4 sustained over a 1 hour period
Neutropenia is defined as an absolute neutrophil count of ______________ or an ANC that is _____________
<500 or one that is expected to decrease <500 within 48 hours
What is the calculation for absolute neutrophil count (ANC)?
ANC = total WBC x (%PMNs + %bands)
If a patient has 800 WBC, 40% PMNs & 20% bands, what is the ANC? Is this patient neutropenic or not?
ANC = 480 because 800 (0.6)
Neutropenic because <500
Then if the patient gets a fever, it is neutropenic fever
Those expected to be neutropenic for <7 days, have no comorbidities (renal or liver) and have undergone solid tumor chemo (breast, lung, of organs or tissue) are low or high risk?
LOW
Those expected to be neutropenic for >7 days, have ongoing comorbidities, and have high risk hematologic cancers such as leukemia are deemed low or high risk?
HIGH
The Max score of the MASCC is ______ and (less/greater) than 21 is _________ risk
26, less than 21 is HIGH RISK
What is the MASCC criteria?
The MASCC Risk Index is an internationally validated scoring system that identifies these low risk patients that can potentially be treated as an outpatient with early antibiotics.
Burden of febrile neutropenia criteria
No or mild symptoms = 5
Moderate symptoms = 3
Severe symptoms =0
What is most common gram negative organism in the setting of neutropenic fever?
Gram - rods (esp Pseudomonas)
Pseudomonas has a high mortality
What is the most common gram + organism in the setting of neutropenic fever?
Staph epidermis
Don’t cover for gram + unless people are at risk
We always treat a patient for which organism in the setting of neutropenic fever?
Pseudomonas
What other pathogen is common in high risk patients and uncommon in low risk?
Fungal
Name two high risk fungal pathogens
Candida and aspergillus
_________ reactivation is also common in neutropenic patients
HSV
What do you treat patients who are at risk for HSV reactivation while having neutropenia?
Acyclovir
The ______ are a common site of infection with neutropenic fever?
Lungs
Also indwelling ports/IV catheters, skin & mucous membranes
What exam should be avoided in patient’s with neutropenic fever due to high risk of introducing infection?
DRE
You need ____ sets of blood cultures then prompt initiation of antimicrobial therapy for a patient with neutropenic fever
2
One set from peripheral line and one set from central line
How do you know if infection is a central line infection?
If central line + and periph + then def central line… If central line - then from periph
You deem your neutropenic patient to be high risk. What imaging do you order?
CT of chest
You deem your neutropenic patient to be low risk. What imaging do you order?
CXR
Anything after ______ (amt of time) is a delayed start to treating neutropenic fever and can show up to 70% mortality
1 hour
In a low risk patient, what med do we treat with first? Must we hospitalize?
Pseudomonas with CIPRO or Levofloxacin AND Amox/Clav… Not always
How do we treat low risk patients with pseudomonas?
CIPRO or Levofloxacin AND Amox/Clav
In a low risk patient, what do we do? Must we hospitalize?
Hospitalize + abx
How do we treat high risk patients?
- Ceftazidime OR Cefepime (preferred)
- Pip/Tazo
- Imipenem or Meropenem
In what instance would you treat a patient with vancomycin in the setting of neutropenic fever?
- First you would start with anti-pseudomonal
- If pt has sepsis, is unstable, has pneumonia on CXR, catheter related infection, skin or soft-tissue infection at site, MRSA
How long do you treat a patient with antimicrobial therapy?
Until no longer neutropenic (10-14 days)
You would use fluroquinolone prophylaxis in a patient with AND < ______
100
How do you prophylaxis for Candidia?
Fluconazole
How do you prophylaxis for Aspergillus ?
Posaconazole
If age 13 and undergoing intensive chemo for AML/MDS
Those with ______ tumors are considered ________ for neutropenic fever and do not need prophylaxis
solid, low risk
Hematopoietic growth factors should be considered in patients who…
are at risk for fever and neutropenia is 20% or greater
Hematopoietic growth factors are not recommended in which patients?
With established febrile neutropenia
