Neutropenic Fever- Schoenwald

Question 1

Neutropenic fever is defined as a fever in the setting of _________ & active ___________

Answer 1

cancer, active chemotherapy

Question 2

Neutropenic fever is usually caused by colonizing _________ or __________ of the _________

Answer 2

bacteria, yeast, GI tract

Chemo can disrupt the mucous membranes of the mouth and GI tract allowing for organisms to enter

Question 3

Chemo suppresses the ___________ system and also __________

Answer 3

the immune system and bone marrow

Also neutropenic so less neutrophils to fight infection

Question 4

What is the fever criteria for neutropenic fever?

Answer 4

A fever >101 OR fever of 100.4 sustained over a 1 hour period

Question 5

Neutropenia is defined as an absolute neutrophil count of ______________ or an ANC that is _____________

Answer 5

<500 or one that is expected to decrease <500 within 48 hours

Question 6

What is the calculation for absolute neutrophil count (ANC)?

Answer 6

ANC = total WBC x (%PMNs + %bands)

Question 7

If a patient has 800 WBC, 40% PMNs & 20% bands, what is the ANC? Is this patient neutropenic or not?

Answer 7

ANC = 480 because 800 (0.6)
Neutropenic because <500

Then if the patient gets a fever, it is neutropenic fever

Question 8

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?

Answer 8

LOW

Question 9

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?

Answer 9

HIGH

Question 10

The Max score of the MASCC is ______ and (less/greater) than 21 is _________ risk

Answer 10

26, less than 21 is HIGH RISK

Question 11

What is the MASCC criteria?

Answer 11

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.

Question 12

Burden of febrile neutropenia criteria

Answer 12

No or mild symptoms = 5
Moderate symptoms = 3
Severe symptoms =0

Question 13

What is most common gram negative organism in the setting of neutropenic fever?

Answer 13

Gram - rods (esp Pseudomonas)

Pseudomonas has a high mortality

Question 14

What is the most common gram + organism in the setting of neutropenic fever?

Answer 14

Staph epidermis

Don’t cover for gram + unless people are at risk

Question 15

We always treat a patient for which organism in the setting of neutropenic fever?

Answer 15

Pseudomonas

Question 16

What other pathogen is common in high risk patients and uncommon in low risk?

Answer 16

Fungal

Question 17

Name two high risk fungal pathogens

Answer 17

Candida and aspergillus

Question 18

_________ reactivation is also common in neutropenic patients

Answer 18

HSV

Question 19

What do you treat patients who are at risk for HSV reactivation while having neutropenia?

Answer 19

Acyclovir

Question 20

The ______ are a common site of infection with neutropenic fever?

Answer 20

Lungs

Also indwelling ports/IV catheters, skin & mucous membranes

Question 21

What exam should be avoided in patient’s with neutropenic fever due to high risk of introducing infection?

Answer 21

DRE

Question 22

You need ____ sets of blood cultures then prompt initiation of antimicrobial therapy for a patient with neutropenic fever

Answer 22

2

One set from peripheral line and one set from central line

Question 23

How do you know if infection is a central line infection?

Answer 23

If central line + and periph + then def central line… If central line - then from periph

Question 24

You deem your neutropenic patient to be high risk. What imaging do you order?

Answer 24

CT of chest

Question 25

You deem your neutropenic patient to be low risk. What imaging do you order?

Answer 25

CXR

Question 26

Anything after ______ (amt of time) is a delayed start to treating neutropenic fever and can show up to 70% mortality

Answer 26

1 hour

Question 27

In a low risk patient, what med do we treat with first? Must we hospitalize?

Answer 27

Pseudomonas with CIPRO or Levofloxacin AND Amox/Clav… Not always

Question 28

How do we treat low risk patients with pseudomonas?

Answer 28

CIPRO or Levofloxacin AND Amox/Clav

Question 29

In a low risk patient, what do we do? Must we hospitalize?

Answer 29

Hospitalize + abx

Question 30

How do we treat high risk patients?

Answer 30

• Ceftazidime OR Cefepime (preferred)
• Pip/Tazo
• Imipenem or Meropenem

Question 31

In what instance would you treat a patient with vancomycin in the setting of neutropenic fever?

Answer 31

• 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

Question 32

How long do you treat a patient with antimicrobial therapy?

Answer 32

Until no longer neutropenic (10-14 days)

Question 33

You would use fluroquinolone prophylaxis in a patient with AND < ______

Answer 33

100

Question 34

How do you prophylaxis for Candidia?

Answer 34

Fluconazole

Question 35

How do you prophylaxis for Aspergillus ?

Answer 35

Posaconazole

If age 13 and undergoing intensive chemo for AML/MDS

Question 36

Those with ______ tumors are considered ________ for neutropenic fever and do not need prophylaxis

Answer 36

solid, low risk

Question 37

Hematopoietic growth factors should be considered in patients who…

Answer 37

are at risk for fever and neutropenia is 20% or greater

Question 38

Hematopoietic growth factors are not recommended in which patients?

Answer 38

With established febrile neutropenia