13 Chemotherapy-Induced Neutropenia Lee Flashcards Preview

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Flashcards in 13 Chemotherapy-Induced Neutropenia Lee Deck (28):
1

What is the most common dose-limiting toxicity of chemotherapy?

Myelosuppression

2

What is Nadir?

The time after chemotherapy at which number of blood cells in the periphery is the lowest

3

What are the life-threatening consequences of Neutropenia?

Increased risk of infection. Prolonged hospitalization for administration of IV abx. Interruptions in cancer treatment. Increased mortality

4

What are the patterns of chemotherapy-induced neutropenia?

Rapid: onset within 10-14 days, recover in 3-4 weeks. Delayed: 4-6 weeks, recovery in 6-8 weeks

5

What is Febrile Neutropenia (FN)?

Absolute neutrophil count (ANC) < 500 cells/mm3 or < 1000 cell/mm3 with a predicted decline to < 500/mm3 within 48 hours. Single temp > 38.2 (101F) or > 37 (100.4) for > 1 hour

6

What are the symptoms to monitor closely with Neutropenia?

Concerned with infection, watch for: Fever and shaking chills, Dizziness or fainting, Redness or swelling of skin or open wound, Respiratory symptoms (cough or sinus congestion)

7

When is the risk for Febrile Neutropenia (FN) the greatest?

When ANC < 100 cell/mm3

8

What are some common pathogens in FN patients?

Primarily bacterial. Gram (+): Staph aureus, Enterococci, Ciridans group streptococci. Gram (-): E. coli, Klebsiella, P. aeruginoa, Enterobacter. Anaerobes infrequent

9

What are some prophylactic antimicrobials for FN?

Levofloxacin. TMP-SMX (at risk for Pneumocystis jiroveci). Fluconazole and Acyclovir

10

What are Low Risk patients for getting infection?

Outpatients. No associated comorbid illness. Solid tumor patients. Serum Cr < 2. LFTs < 3x normal

11

What are High Risk patients for getting infection?

In-patient. Associated comorbid illness that requires hospitalization. Uncontrolled/progressive cancer. Prolonged neutropenia (< 100 for > 7 days). Pneumonia. Advanced age. Stem cell recipients

12

What does a score of 21 or higher indicate in the MASCC/IDSA scoring index?

Patient is likely to be at low risk for complications with FN

13

What is the initial antibiotic regimen to start for FN?

Promptly start broad-spectrum antibiotics. Empiric = reliable coverage of most likely bugs. Bactericidal. Antipseudomonal agent. Stepwise approach if fever persists

14

What is the usual oral abx used for low risk patients with FN?

Cipro + Amoxacillin-Clavulanate. Reassess after 3-5 days

15

What are the usual choices for abx in low risk FN patients who require IV treatment?

Cefepime. Ceftazidime. Zosyn. Carbapenem. Aztreonam + Vancomycin (if PCN or cephalosporin allergy). Reassess after 3-5 days

16

What is reassessment of antibiotic regimen during 1st week like?

At least 3 days of tx usually required to assess efficacy. Time to defervesce for FN cancer patients ranges from 2-7 days

17

What is done for high risk FN patients who need Vanco?

Vancomycin + Zosyn, Cefepime or carbapenem +/- AG. Reassess after 3-5 days

18

What is done for high risk FN patients who do not need Vanco?

Two drugs: AG + Zosyn, Cefepime, or Carbapenem. Reassess after 3-5 days

19

When is Vanco usually added?

B-lactam allergy (vanco + Aztreonam). Catheter-related cellulitis (coag neg Staph). Known colonization w/ PCN- or Ceph-resistant penumococci or MRSA. Isolation of gram positive bacteria from blood. Severe mucositis (Ara-C). Quinolone prophylaxis for afrebrile neutropenia. Clinically unstable (hypotension, septic shock)

20

What needs to be added to patients regimen if febrile through days 5-7 and resolution of neutropenia is not imminent?

Add antifungals with or without antibiotic change

21

When can FN therapy be stopped?

If ANC > 500 x2 consecutive days + if afebrile for 48hrs + clinically well

22

When are systemic fungal infections common in FN patients?

Prolonged (7+ days) and profound neutropenia. Severe mucosal damage. Underlying disease (BMT, AML). Presence of CVC, steroids, broad spectrum antibiotics exposure

23

What are the most common fungal pathogens in FN patients?

Candida. Aspergillosis. Other molds: Fusarium, Mucor, Rhizopus

24

What are the Granulocytes-CSF (Colony Stimulating Factors) used?

Filgrastim (Neupogen): 5mcg/kg SQ QD x7-10 days. Pegfilgrastim (Neulasta) - long acting: 6mg fixed SQ once/CT cycle or Q3 weeks

25

What are the Granulocyte-Macrophage-CSF (Colony Stimulating Factors) used?

Sargramostim (Leukine): 250mcg/m2 SQ daily

26

What is a caution with Pegfilgrastim (Neulasta) use?

This medication is NOT to be administered during the time interval beginning 14 days before to 24h after administration of chemotherapy

27

When do you begin CSFs and for how long?

Begin 24-72hrs post chemo. Continue past Nadir until ANC >10,000/mcL (~7-14 days). Alternative: Use for shorter duration until clinically adequate neutrophil recovery, i.e. ANC 2-3,000/mcL

28

What are the ADRs associated with CSF?

Fever, HA, Bone/joint pain, myalgia (tylenol can be used for these). Injection site reaction. Dyspnea, fluid retention (less common). Splenic rupture