Febrile Neutropenia Flashcards by Nicole Gaudreau

What is the definition of febrile neutropenia?

Oral temp > 101F (38.3C)
OR
Oral T > 100.4F (38C) for one hour
PLUS
Neutrophil count < 500 
OR
Neutrophil < 1000 with a predicted nadir to < 500

How well did you know this?

Not at all

Perfectly

What is nadir?

Lowest neutrophil count usually occurs 7-14 days post-chemotherapy

How well did you know this?

Not at all

Perfectly

What is believed to cause the majority of febrile neutropenic episodes?

Seeding of the bloodstream from endogenous flora in the GI tract

How well did you know this?

Not at all

Perfectly

What is the most commonly isolated pathogen in febrile neutropenia?

Coagulase negative staphylococcus

How well did you know this?

Not at all

Perfectly

What is the most common fungus in febrile neutropenia?

Candida albicans

How well did you know this?

Not at all

Perfectly

What viruses are common in febrile neutropenia?

HSV
EBV
CMV
Influenza
RSV

How well did you know this?

Not at all

Perfectly

What are gram positive pathogens in febrile neutropenia?

Coagulase negative staph
Staph aureus
Enterococcus
Strep (veridians, pneumoniae, pyogenes)

How well did you know this?

Not at all

Perfectly

What are gram negative bacteria in febrile neutropenia?

E coli
Klebsiella
Enterobacter
Pseudomonas aeruginosa
Citrobacter
Acinetobacter
Stenotrophomonas

How well did you know this?

Not at all

Perfectly

What are the candida species in febrile neutropenia?

Albicans
Tropicalis
Glabrata
Krusei

How well did you know this?

Not at all

Perfectly

What are invasive mold infection that are possible with profound, prolonged neutropenia?

Aspergillosis
Zygomycoses
Fusariosis

How well did you know this?

Not at all

Perfectly

What is done in the initial patient evaluation in febrile neutropenia?

PE
Patient hx
Initial lab tests/procedures

How well did you know this?

Not at all

Perfectly

What lab tests/procedures are done in febrile neutropenia?

At least 2 blood cultures (prior to initiation of abx)
Cultures from any site of suspected infection (prior to initiation of abx)
CBC w/differential
BMP
Hepatic transaminases
T bili

How well did you know this?

Not at all

Perfectly

A patient that is considered high risk will get what?

Admission to hospital

IV abx

How well did you know this?

Not at all

Perfectly

A patient that is considered low risk will get what?

Outpatient tx

PO abx

How well did you know this?

Not at all

Perfectly

What are high risk patients?

Profound neutropenia expected to last more than 7 days
Significant co-morbid conditions/presenting s/sx
MASCC score < 21

How well did you know this?

Not at all

Perfectly

What are considered significant co-morbid conditions/presenting s/sx?

Hemodynamic instability
Oral/GI mucositis, GI sx
Mental status changes
New pulmonary infiltrates, hypoxemia, underlying lung disease
Hepatic insufficiency
Renal insuffiency

How well did you know this?

Not at all

Perfectly

What are considered low risk patients?

Anticipated brief neutropenia
No/few co-morbidities
MASCC score greater than or equal to 21

How well did you know this?

Not at all

Perfectly

When reading a MASCC score, what is considered a low risk patient?

21 or higher (max is 26)

How well did you know this?

Not at all

Perfectly

Immediately after the blood culture, what do we do?

Give empiric abx

How well did you know this?

Not at all

Perfectly

What are the empiric therapies for febrile neutropenia?

Cefepime
Imipenem/cilastatin
Meropenem
Pip/tazo
Ceftaz

How well did you know this?

Not at all

Perfectly

Empiric treatment uses which type of abx for empiric therapy?

Study These Flashcards

Anti-pseudomonal beta-lactams

When should vancomycin be added to empiric abx therapy?

Study These Flashcards

Hemodynamic instability/sepsis
Radiographically documented pneumonia
Blood culture + for staph before culture finalized
Clinically suspected catheter related infection
Suspected skin/soft tissue infection
Colonization with MRSA or PCN resistant streptococcus

What are indications for other empiric abx?

Study These Flashcards

H/o VRE (linezolid, dapto)

H/o KPCs (polymyxin-colistin, tigecycline)

What abx are given for outpatient tx?

Study These Flashcards

Cipro + augmentin
FQ may be considered
Clinda may be substituted for augmentin in hypersensitivity

What is assessed at 48 hours?

Cultures = abx therapy change If vanc initiated empirically, may be stopped at 48 hours if no gram+ growth Hemodynamically stable, consider transition to PO abx Hemodynamically unstable patients with fever, abx coverage broadened

When do we see oral lesions/esophagitis and how do we treat it?

HSV | Consider acyclovir and/or fluconazole

When do we see ab pain and how do we treat it?

Neutropenic enterocolitis | Pip/tazo monotherapy

What do we do if there is recurrent or persistent fever for > 72 hours despite empirical abx therapy warrants evaluation?

Additional blood cultures Thorough search for source of infection Non-infectious source of fever

When is empiric antifungal coverage considered in high risk patients?

After 4-7 days of broad spectrum abx coverage and no identitified fever source

If the patient is receiving fluconazole prophylaxis, what do we consider is the cause?

Resistant candida species or evasive fungal infection

What do we give if the candida strain is fluconazole resistant?

Ampho B Capsofungin Voriconazole

When do we use antibacterial prophylaxis?

High risk patients with expected profound and prolonged neutropenia ANC less than or equal to 100 for > 7 days

What medications do we prophylactically treat for febrile neutropenia?

When is antifungal prophylaxis recommended?

For allogeneic HSCT recipients or those undergoing remission-induction or salvage induction chemotherapy for acute leukemia

With which medication do we prophylax for fungal infections?

Fluconazole

When is viral prophylaxis recommended?

Patients who are HSV-seropositive

What medication is used for viral prophylaxis?

Acyclovir

When should the influenza vaccine be administered?

Greater than 7 days post-chemo or > 2 weeks before chemo

Which MGFs do we start 1-3 days after completion of chemotherapy cycle?

Filgrastim Pegfilgrastim Sargramostim

When do we not use pegfilgrastim?

Regimens scheduled < 2 weeks apart

What are G-CSFs?

Filgrastim | Pegfilgrastim

What is GM-CSF?

Sargramostim

What is G-CSF approved for?

Prevention of chemo-induced neutropenia

What is GM-CSF approved for?

Following induction therapy for AML/stem cell transplantations

What are the AEs of MGFs?

``` Fever N/V/D Bone pain*** HTN Hyperglycemia ```

When are MGFs used as primary prophylaxis?

During the first cycle of myelosuppressive chemotherapy | Goal of preventing neutropenic complications

When are MGFs used as secondary prophylaxis?

Subsequent chemo cycles after neutropenic fever has occurred in a prior cycle

Above what % incidence is primary prophylaxis recommended?

greater than or equal to 20% anticipated febrile neutropenia

Which patients may MGF primary prophylaxis be justified?

``` > 65 yo receiving full dose intensity Bone marrow involvement Renal dysfunction Liver dysfunction Recent surgery or open wounds Active infection ```

By what percent does GMF use as secondary prophylaxis reduce the risk of febrile neutropenia?

50%

What are RFs for poor clinical outcomes of febrile neutropenia?

``` Age > 65 Sepsis syndrome Severe neutropenia (ANC < 100) Prolonged neutropenia (> 10 days in duration) Pneumonia Invasive fungal infection Other clinically documented infections Hospitalization at time of fever Prior episode of febrile neutropenia ```

Febrile Neutropenia Flashcards

(51 cards)