13 Chemotherapy-Induced Neutropenia Lee Flashcards

1
Q

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

A

Myelosuppression

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2
Q

What is Nadir?

A

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

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3
Q

What are the life-threatening consequences of Neutropenia?

A

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

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4
Q

What are the patterns of chemotherapy-induced neutropenia?

A

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

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5
Q

What is Febrile Neutropenia (FN)?

A

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

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6
Q

What are the symptoms to monitor closely with Neutropenia?

A

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)

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7
Q

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

A

When ANC < 100 cell/mm3

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8
Q

What are some common pathogens in FN patients?

A

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

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9
Q

What are some prophylactic antimicrobials for FN?

A

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

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10
Q

What are Low Risk patients for getting infection?

A

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

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11
Q

What are High Risk patients for getting infection?

A

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

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12
Q

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

A

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

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13
Q

What is the initial antibiotic regimen to start for FN?

A

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

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14
Q

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

A

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

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15
Q

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

A

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

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16
Q

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

A

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

17
Q

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

A

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

18
Q

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

A

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

19
Q

When is Vanco usually added?

A

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
Q

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

A

Add antifungals with or without antibiotic change

21
Q

When can FN therapy be stopped?

A

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

22
Q

When are systemic fungal infections common in FN patients?

A

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

23
Q

What are the most common fungal pathogens in FN patients?

A

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

24
Q

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

A

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

25
Q

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

A

Sargramostim (Leukine): 250mcg/m2 SQ daily

26
Q

What is a caution with Pegfilgrastim (Neulasta) use?

A

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

27
Q

When do you begin CSFs and for how long?

A

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
Q

What are the ADRs associated with CSF?

A

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