Schoenwald Flashcards by Alice Richards

what are the 2 main symptoms of neutropenic fever

fever (earliest symptom)
sores along mucous membranes of the GI tract

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what does a microbiologically documented infxn mean

culture positive

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what does a clinically documented infxn mean

ex cellulitis

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what is an unexplained fever

no clinical focus or culture positive material

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what are important hx factors to take into account w. neutropenic fever (3)

GI risk factors
previous infxn → what organism?
non-infectious causes

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what are 2 non infectious causes of neutropenic fever

blood transfusion
comorbidities

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what exam should you AVOID w. neutropenic fever

DRE!!

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what are some common sites of infxn w. neutropenic fever

lungs
indwelling ports/IV catheters
skin and mucous membranes
perianal → but avoid DRE!

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what is the definition of neutropenia relative to ANC count

absolute neutrophil count (ANC) < 500 cell/microL

an ANC expected to decrease to at least 500 cell/microL w.in 48 hr

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what is the equation for ANC

total WBC x (%PMNs + %bands)

ex. total WBC = 1,000

PMNs = 30%

bands = 10%

→ 1,000 x 40%

ANC = 400

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how many blood cultures do you need to dx neutropenic fever

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what 2 sites do you need blood cultures from to dx neutropenic fever

one from periphery
one from port or line

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what needs to be done prior to initiation of antimicrobial therapy in neutropenic fever

2 blood cultures

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how can you tell if an infxn is a line infxn

there is at least a 2 min delay btw line and culture positives and line was first

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besides cultures, what are other lab tests for neutropenic fever (6)

CBC

CMP

UA w. culture

sputum culture

stool culture w. C.diff

LP/CSF if HA

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should you delay antimicrobial therapy for neutropenic fever to wait for labs other than blood cultures?

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what imaging should you order for low risk neutropenic fever pt

CXR

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what imaging should you order for high risk neutropenic fever pt

chest CT

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what is the definition of neutropenic fever

fever in setting of ca and active chemo receiving cytotoxic antineoplastic therapy

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what are the fever parameters for neutropenic fever

single temp measured at 38.3 C (101F)

38.0 C (100.4F) sustained over 1 hr

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what pathogens are associated w. neutropenic fever

colonizing bacteria or yeast of GI tract

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what pathogen is most commonly associated w. neutropenic fever

pseudomonas → high mortality

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what is the most common gram positive organism associated with neutropenic fever

staph epidermidis

(MRSA becoming more common in setting of MDRO)

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what is the two most common fungal pathogens associated with neutropenic fever

candida

Aspergillus

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\_\_ and \_\_ pathogens are associated w. high mortality in neutropenic fever

pseudomonas fungal

fungal pathogens are are more commonly associated with __ patients in neutropenic fever

high risk

what are the most common viral pathogens in neutropenic fever

1. herpes simplex 2. shingles reactivation

what is the definition of a low risk pt in neutropenic fever (3)

1. expect to be neutropenic \<7 days 2. no comorbidities 3. most solid tumor regimens

what is the definition of high risk neutropenic fever (3)

1. expect neutropenia \>7 days 2. ongoing comorbidities 3. hematologic cancers (esp leukemias; also lymphomas etc)

what is used for antiviral prophylaxis for neutropenic fever

Acyclovair 400-800 mg po

what 2 patient populations are given Acyclovair prophylaxis for neutropenic fever

1. leukemics starting therapy 2. HSCT (bone marrow transplant pt's)

what drug is given for aspergillus prophylaxis in neutropenic fever

posaconazole → 13 yo and older and undergoing intense chemo for AML/MDS (myelodysplastic syndromes)

what drug is given for candida prophylaxis in neutropenic fever

fluconazole

what 2 patient populations are given fluconazole prophylaxis for neutropenic fever

1. leukemics starting tx 2. HSCT (bone marrow transplants)

what prophylactic drug is given for expected prolonged neutropenia w. ANC \< 100

fluoroquinolones

are pt w. solid tumors given prophylaxis for neutropenic fever?

no! → they are low risk

what pt population is given hematopoietic growth factor for neutropenic fever

consider in pt w. anticipated risk of fever, and neutropenia is 20% or higher

hematopoietic growth factor is not recommended for

pt w. established febrile neutropenia

in terms of tx initiation, neutropenic fever is considered a

medical emergency

1st step in tx of neutropenic fever

empiric abx asap w.in 1 hr!

tx for neutropenic fever is considered delayed if it is given in

1 hour

abx for neutropenic fever focus on __ pathogens, but __ pathogens should be considered for more complicated pt

gram negative gram positive

what is the tx for low risk neutropenic fever pt's

oral abx → Fluoroquinolones (Cipro or Levo) PLUS Amoxicillin Clauv 500/125 mg po tid

what is the tx for high risk pt's for neutropenic fever

require hospitalization and IV abx: 1. **Cefepime 2 gm IV q 12 hr (BID)** 2. Piperacillin/Tazobactam (Zosyn) 4-5 g IV q 6 hr (TID) 3. Imipenem OR Meropenem for more resistant organisms 4. Vancomycin only if MRSA is suspected

what is the abx duration for neutropenic fever

until neutropenia is resolved → ANC \> 500

what is the MASCC risk score?

what is the “low risk” score for MASCC

21 or higher

a MASCC score of 5 indicates

no/mild sx

a MASCC score of 3 indicates

moderate sx

a MASCC score of 0 indicates

severe sx/moribund

what is functional neutropenia

suppressed immune system in the setting of adequate neutrophil count

what 2 PE exam findings would make you suspect osteomyelitis

1. bone can be probed w. a swab from the wound site 2. a wound is present \> 6 weeks duration

what imaging is used to dx osteomyelitis

plain film xray

what imaging is used to evaluate osteomyelitis if the initial xray is negative, but you have a high suspicion for osteo

MRI

what are the 2 main symptoms of osteomyelitis

1. fever 2. bone or joint tenderness/pain

what do labs show in osteomyelitis

elevated acute phase reactants

what are 5 RF for osteomyelitis

1. bone fx 2. weakened immune system (DM, AIDS) 3. kidney failure 4. IV drug use 5. joint replacement/hardware 6. peripheral neuropathy

osteomyelitis is __ or \_\_ infxn of bone

bacterial fungal

what are the 3 infectious sources of osteomyelitis

1. hematogenous 2. invasion from a contiguous focus of infxn → DM foot ulcer 3. skin breakdown → vascular insufficiency or trauma

what 3 sources of bacteremia is hematogenous osteomyelitis associated with

1. sickle cell anemia 2. elderly 3. IV drug users

what bacteria do you think of when you see sickle cell anemia and osteomyelitis

salmonella

what bacteria do you think of when you see sickle cell anemia, elderly, and IV drug users

staph aureus