Febrile Neutropenia EXAM 2 Flashcards
(25 cards)
What is the definition of Neutropenia?
Absolute Neutrophil Count (ANC) < 500
less than 0.5 x 10^9/L
or
< 1000 (1 x 10^9/L) with expected fall to <500 in the next 48 hours
for neutropenic fever:
they also have to have a temperature of >100.4°F (38°C)
How many days after chemotherapy do you expect the lowest point of ANC (nadir)?
10-14 days after chemo
When is the risk for mucositis high after chemotherapy?
10-14 days after chemo
bc the mucsoal cells (rapidly dividing) are killed by the drugs
-risk for infections
-risk for mucositis
What is the ANC of a patient with a
WBC = 1.2 x 10^9/L with 10% neutrophils, 80% lymphocytes, 10% monocytes, & 0% bands?
1200 is the total number of WBC (contains neutrophils, eosinophils, basophils, lymphocytes, monocytes)
10% of 1200 = 120
What is the ANC of a patient with a
WBC = 1.2 x 10^9/L with 10% neutrophils, 70% lymphocytes, 10% monocytes, & 10% bands?
total = 1200
10% neutrophils = 120
10% bands (immature neutrophils) = 120
ANC = 240
What are the risk factors of neutropenic fever?
-age (old bone marrows, take longer to recover)
-chemotherapy regimen (some are more myelosuppressive, # of cycles)
-type of malignancy (hematologic at highest risk)
-concomitant radiation (depending where in the body, some bones have more bone marrow)
Which pathogens should be covered with Febrile Neutropenia?
often from our own cavity or GI -> need broad coverage
Gram + with MSSA and MRSA
Gram - E. coli, Pseudo, Klebsiella
Which pathogens should be covered with prolonged leukopenia and lymphopenia
-Fungus
-Viruses (prolonged lymphopenia)
in addition to Gram (+) and (-)???
Factors that make a patient high-risk for febrile neutropenia
-hypotension (SBP <90)
-COPD
-hematological or solid tumor with previous fungal infection
-dehydration
-hospital
-age >60y
How are high and low-risk patients treated differently?
high risk: need IV
most patients are high risk, if in the hospital they are high hrisk
low risk: oral antibiotics
Rank these patients from highest (at the top) to lowest risk of neutropenic fever.
A 65-year-old male receiving cytarabine & doxorubicin for acute leukemia.
A 50-year-old receiving their 4th cycle of doxorubicin, docetaxel, & cyclophosphamide for breast cancer.
A 50-year-old receiving their 1st cycle of doxorubicin and cyclophosphamide for breast cancer.
A 65-year-old male receiving cytarabine & doxorubicin for acute leukemia
-age is higher
-acute leukemia (blood cancer) treatment has a higher risk for neutropenia
Which pathogen is NOT covered by Cefepime?
anaerobes
if anaerobes need to be covered:
go with Pip/Tazo, it covers everything Cefepime covers + anaerobes
What is different about the coverage profile of Meropenem compared to Pip/tazo?
Meropenem has the same coverage as Pip/tazo
+ ESBL
What is the dose of Pip/Tazo used in patients with Febrile neutropenia?
4.5 g IV Q6h
renal dose adjustment: 3.375 g IV Q6h
Broad spectrum PO regimen
Augmentin + Cipro
Gram +: Augmentin (clavulanate gives some anaerobic coverage)
Pseudomonas and other Gram (-) : Ciprofloxacin
-treat until ANC >500
What are the antipseudomonal ß-lactams used for neutropenia high-risk patients?
-Pip/Tazo
-Cefepime
-Meropenem
-Imipenem/cilastatin (not often used)
if they are septic, have persistent fever, culture is growing gram (-) add gram (-) coverage
-Aminoglycoside
-Cipro
What is the dose of Cefepime used in patients with Febrile neutropenia?
2g IV Q8h
What are the 6 criteria that determine Vancomycin treatment?
!!!
- pneumonia
- suspected line infection (central catheter, or port placed)
- blood culture is growing gram (+)
- hx of MRSA, resistant strep pneumo
- septic, hemodynamically unstable, low BP, high HR
- skin and soft tissue infection
use broad spectrum antibiotic + VNC
-check the WBC and temperature, check antibiotics if no improvement after 3 days based on the culture
When do we need Febrile Neutropenia prophylaxis, and which drugs are used?
-if we think the ANC will be below 100 for a week
-drug of choice: Levofloxacin
others: Cipro
-Antifungal: Flucanozole
-Antiviral: Acyclovir
(consider antifungal, antiviral for hematopoietic stem cell transplant (HSCT) patients)
What is the dose for Cipro and Levo in Febrile Neutropenia prophylaxis?
Cipro: 500 mg Q12
Levo: 500 or 750 mg daily
Which cancer diseases are known to cause febrile neutropenia for more than a week and may require prophylaxis?
-acute leukemia
-some lymphomas
When is prophylaxis for Pneumocystis jirovecii pneumonia PJP required?
-ALL (acute lymphocytic leukemia) patients
-pts on fludarabine
-pts on alemtuzumab
-temozolomide for Glioblastoma treatment
-prednisone equivalent 20 mg /day for 1 month
Which drug is used for PJP prophylaxis? Which ones in case of an allergy to the preferred drug?
Bactrim DS (160TMP/800 SMX) daily M-W-F
or BID for Sat/Sun
in case of sulfa allergy
-inhaled pentamidine 300 mg
-Dapsone
Which drugs should be avoided in febrile neutropenia patients to assess their fever?
NSAIDs
Tylenol
bc we want to assess the patient’s fever, they are antipyretic
