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Spring 2025 Therapeutics V > Exam 5: Infections in Immunocompromised Patients > Flashcards

Exam 5: Infections in Immunocompromised Patients Flashcards

(67 cards)

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1
Q

What are the 4 risk factors for developing infection?

A

Neutropenia

Immune System Defects

Destruction of Protective Barriers

Environmental contamination/alteration of microbial flora

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2
Q

What is Neutropenia?

A

-Reduction in the number of circulating neutrophils

-ANC < 1000

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3
Q

How do we calculate ANC?

A

WBC x (%polys + %bands)

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4
Q

What are the 2 types of immune system defects?

A

Defect in cell-mediated immunity

Defect in humoral immunity

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5
Q

What are the common fungi that cause infections?

A

Candida spp

Aspergillus

Zygomycetes

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6
Q

What are the common viruses that cause infection?

A

Herpes Simplex Virus (HSV)

Varicella Zoster Virus (VZV)

Cytomegalovirus (CMV)

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7
Q

What is affected in cell-mediated immunity defects?

A

T-lymphocytes

-Primary defense is against INTRACELLULAR pathogens

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8
Q

What is affected in humoral immunity defects?

A

B-lymphocytes

-Primary defense is against EXTRACELLULAR pathogens

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9
Q

What are 2 causes of both cell-mediated and humoral immunity defects?

A

Underlying disease

Immunosuppressive drugs

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10
Q

What are the “extracellular pathogens”?

A

Bacteria (encapsulated):

-S. pneumoniae
-H. influenzae
-N. meningitidis

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11
Q

What is the most common cause of mucous membrane destruction (protective barrier)?

A

Chemotherapy

Radiation

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12
Q

What surgery patients have the highest risk of infection?

A

Solid organ transplant patients

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13
Q

Oropharyngeal flora rapidly change to what in hospitalized patients?

A

Gram-negative bacilli

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14
Q

What is the leading cause of death in neutropenic cancer patients?

A

Infection

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15
Q

The greatest risk of infection occurs in which neutropenic patients?

A

Those with profound neutropenia

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16
Q

What is the definition of profound neutropenia?

A

ANC < 500

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17
Q

Bacteremic episodes in cancer patients are predominantly due to which type of organism?

A

Gram-positive cocci

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18
Q

Who is at the highest risk for an invasive fungal infection?

A

Prolonged neutropenia
+
Broad-spectrum antibiotic and/or steroid use

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19
Q

What is the most common fungal infection?

A

Candida albicans

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20
Q

Up to what % of cancer patients develop thrush?

A

60%

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21
Q

An aspergillus infection can cause what in cancer patients?

A

Prolonged neutropenia

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22
Q

How is aspergillus spread?

A

Inhalation of airborne spores
-then lung colonization
-invades parenchyma and pulmonary vessels
-leads to hemorrhage and pulmonary infarcts
-may cause mortality

*note that it can cause sinusitis and disseminated disease

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23
Q

How does HSV cause infection in cancer patients?

A

Patients have had an infection in the past

The virus reactivates and can manifest as an oral or genital infection

Dissemination is rare but possible

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24
Q

How does pneumocystis jirovecii (PJP) appear in cancer patients?

A

Severe lung infection

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25
How does Toxoplasma gondii appear in cancer patients?
Lung, Brain, and Eye disease
26
What drug is used as prophylaxis for Pneumocystis jirovecii (PJP) and Toxoplasma gondii infections?
Trimethoprim-Sulfamethoxazole
27
What is the most important clinical finding to indicate the presence of an infection?
FEVER -may be the only clinical finding
28
What is the definition of a fever?
Single oral temperature >/= 38.3C (>/= 101F) OR Oral temperature >/= 38C (>/= 100.4F) persisting for 1 hour or longer
29
What is our first step for determining therapy to manage febrile neutropenia?
Infection risk assessment
30
What can an infection risk assessment help us determine regarding what therapy we will use for febrile neutropenia?
IV vs PO Inpatient vs Outpatient Duration
31
What are the criteria for "Low Risk" when conducting an infection risk assessment?
Neutropenia
32
What are the criteria for "High Risk" when conducting an infection risk assessment?
ANC 7 days Clinically unstable Must be inpatient, IV therapy
33
Febrile neutropenia regiments need to have coverage against what?
Pseudomonas
34
For patients with fever and neutropenia who are low risk, have adequate outpatient infrastructure, and are able to take oral therapy, what is the treatment?
Oral FQ + Amox/Clav
35
For a patient with fever and neutropenia who is low risk, has inadequate outpatient infrastructure, or is not a candidate for oral therapy, what it the treatment?
Inpatient IV antibiotics (monotherapy) -Piperacillin/Tazobactam -Antipseudomonal carbapenem -Cefepime Ceftazidime consider step down therapy when able
36
For patients with fever and neutropenia that are at high risk, what is the treatment?
Inpatient IV antibiotics (monotherapy) -Piperacillin/tazobactam -Antipseudomonal -Cefepime Ceftazidime Consider adding vanco Add septic shock coverage if needed
37
What are the beta-lactam monotherapies used in febrile neutropenia?
*Cefepime *Piperacillin/Tazobactam Ceftazidime Imipenem Meropenem
38
What is a downside to using ceftazidime and the reason why we may not choose it for neutropenic fever?
No Gram-positive activity
39
True or False: Vancomycin is not recommended as a standard part of initial empiric therapy for febrile neutropenia
True
40
When do we give vancomycin in febrile neutropenia?
-Hemodynamically unstable/sepsis -Pneumonia -Blood cultures have Gram+ bacteria -Line/port infection -SSTI -Severe mucositis -Colonization by resistant Gram + bacteria
41
What is the preferred therapy for febrile neutropenia in patients with a Type I penicillin allergy (hives, anaphylaxis)?
Ciprofloxacin + Aztreonam + Vancomycin
42
What are the possible treatment regimens for Low-Risk patients with Febrile Neutropenia?
Ciprofloxacin + Amox/Clav Levofloxacin Ciprofloxacin + Clindamycin
43
What are the caveats to using the low-risk febrile neutropenia regimens?
-Requires patient compliance -Patient must have 24-hr access to medical care incase of instability -DO NOT USE in patients already on FQ prophylaxis
44
How long after empiric therapy being started should febrile neutropenia be re-evaluated?
48-72 hrs
45
What is the median time to defervescence (time it takes for pt's fever to go away) in febrile neutropenia?
5-7 days
46
What is the targeted therapy for MRSA?
Vancomycin
47
What is the targeted therapy for VRE?
Daptomycin or Linezolid
48
What is the targeted therapy for ESBL?
Carbapenem
49
What are the targeted therapies for KPC?
Meropenem/Vaborbactam Imipenem/Cilastatin/Relebactam Ceftazidime/Avibactam
50
What is the targeted therapy for NDM/IMP/VIM?
Cefiderocol
51
Who should we consider using antifungal therapy in with febrile neutropenia?
Have persistent fever or develop new fever with undocumented infection after 4-7 days of broad-spectrum antibiotics
52
What are the antifungal treatment options in neutropenic fever?
Amphotericin B deoxycholate Liposomal Amphotericin B Azoles (fluconazole, voriconazole, posaconazole, isavuconazole) Echinocandins (micafungin, caspofungin, anidulafungin)
53
How long should antifungal therapy last in febrile neutropenia?
2 weeks or duration of neutropenia
54
When should we start antiviral therapy in neutropenic fever?
If presence of vesicular/ulcerative skin or mucosal lesions -antivirals aid in healing and prevent dissemination
55
What are the treatment options for antiviral therapy in Febrile Neutropenia?
HSV/VZV: -Acyclovir -Valacyclovir CMV: -Ganciclovir -Valganciclovir
56
What are the indications for catheter removal?
Subq tunnel infection Failure to clear blood cultures after 72 hrs of appropriate antimicrobial therapy Persistent fever Septic emboli Pathogens: -Fungi -P. aeruginosa -Bacillus -C. jeikeium
57
What is the most important determination of patient outcomes with neutropenic fever?
Resolution of neutropenia
58
What drugs can be used to get a patient out of neutropenia faster?
Colony-Stimulating factors -Filgrastim -Sargramostim
59
Who should receive prophylaxis for neutropenic fever?
Moderate and high risk patients with expected ANC7 days Heme malignancies (AML, MM, Lymphoma, CLL) Allogenic and autologous HSCT GVHD with high-dose sterouds **Anyone using alemtuzumab
60
What therapies can we use for neutropenic fever prophylaxis?
Fluoroquinolones -Ciprofloxacin -Levofloxacin
61
What is an important thing to remember about FQ prophylaxis for neutropenic fever?
If breakthrough infection occurs while on FQ, do not use an FQ in their empiric treatment! -assume resistance
62
Who should receive antifungal prophylaxis?
Allogeneic HSCT Intensive induction chemotherapy for acute leukemia
63
What are our antifungal prophylaxis therapy options?
Azoles Echinocandins For AML, MDS, GVHD, on high-dose steroids: -Posaconazole -Isavuconazole
64
Who should receive antiviral prophylaxis?
HSV seropositive patients undergoing allogeneic HSCT or leukemia induction therapy
65
What are our therapy optuons for antiviral prophylaxis?
Acyclovir Varicella vaccine Inactivated flu vaccine
66
Who should receive TMP/SMX prophylaxis?
Allogeneic HSCT Graft-vs-host disease
67
TMP/SMX prophylaxis reduces the risk of what?
PJP pneumonia

Spring 2025 Therapeutics V (41 decks)

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