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bcop- joey > Infectious Disease > Flashcards

Infectious Disease Flashcards

1
Q

When is FQ ppx indicated?

A

Anticipated neutropenia ANC< 100 for > 7 days

give while neutropenic

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2
Q

Who gets primary ppx w/ antifungal agent?

A

-acute leukemia pts receiving intensive remission INDUCTION therapy
-pre-engraftment phase following HCT
->10% risk candidiasis or >6% risk aspergillus
-give during periods of neutropenia!!!

-CONSIDER IF: Profound/prolonged neutropenia- ANC<100 for >7day

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3
Q

Antifungal primary ppx- AML/MDS

A

Posaconazole

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4
Q

Antifungal primary ppx- ALL

A

Fluconazole, echinocandin, or ampho B

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5
Q

Who gets secondary anti-fungal ppx?

A

IDSA: prior IFI and expected neutropenia duration 14+ days

NCCN: during subsequent chemo cycles or HCT in pts with prior IFI

Antifunal ppx is given for duration of immunosuppression even if neutropenia resolves (this is different than primary ppx which is given during periods of neutropenia

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6
Q

Who gets HSV ppx? Which drugs are used?

A

-pts undergoing acute leukemia induction
-CLL (if purine analog, bendamustine, or alemtuzumab)
-alemtuzumab-regardless of CD4 count
-polatuzumab
-give during active therapy
-CD38 mAb

-consider for purine analog therapy
-consider for other hematologic malignancies
-hairy cell leukemia (x3 months after therapy and CD4 200+)

-acyclovir, valacyclovir, famciclovir

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7
Q

Who gets VZV ppx? Which drugs are used?

A

-pts w/ impaired cellular immunity (allogenic HCT)
-consider also for prolonged neutropenia, and t-cell depleting agents (Fludarabine, alemtuzumab- regardless of CD4) or proteosome inhibitors
-give during active therapy

-acyclovir, valacyclovir, famciclovir

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8
Q

Who gets pjp ppx? Which meds are used?

A

-chemo regimens w/ >3.5% risk
->= 20 mg pred x at least one month, or >30 mg x >3weeks
-purine analog based therapy for >1mo
-ALL throughout anti-leukemic therapy
-alemtuzumab
-PI3K inhibitors
-TMZ + RT
-polatuzumab
-give during active therapy or until CD4 count >200 for alemtuzumab
-CLL: bendamustine based immunotherapy
-hairy cell leukemia (x3 months after therapy and CD4 200+)

*Bactrim, dapsone, aerosolized or IV pentamidine, atovaquone

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9
Q

High risk ABX for cdif

A

FQ, clindamycin, cephalosporins

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10
Q

Aspergillus treatment

A

DOC: voriconazole

Alternatives: amphoterecin liposomal(esp if 3a4 interactions ), isavuconazole

Duration: 6-12 weeks or even months-years

don’t use echinocandin upfront

***Use TDM for voriconazole with a goal trough if 2-5 mcg/L

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11
Q

Mold (e.g., aspergillus) ppx

A

Posaconazole

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12
Q

Triazole drug interactions (3A4)

A

Fluconazole and isavuconazole less severe

-vinca alkaloids
-HD-cyclophosphamide
-thiotepa
-PO small molecules (e.g., dasatinib, venetoclax, midostaurin)

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13
Q

Separation of vaccines from chemo

A

-Live: give at least 4 wks before chemo (risk of infxn)

-Inactivated: give at least 2 weeks before chemo (vaccine won’t work- will need to repeat)

if can’t do before, give vaccine 3 months after chemotherapy

or 6 months after anti B-cell therapy

-Covid vaccine:
-solid tumor- vaccinate when available
-heme CA- hold until ANC recovers
-HCT or CAR-T- revaccinate 3 months after

Flu:
-anti-B cell antibodies: 6 mo after
-CAR-T/BiTE (blinatumomab)1 yr after

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14
Q

Flu vaccine

A

-give normal age appropriate
-these people should not get it:
-b cell antibodies within 6 months
-intensive chemo induction (acute leukemia)
-blinatumomab
-CAR-T

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15
Q

Pneumococcal

A

-PCV15 or PCV20 for newly diagnosed

-PPSV23 at least 8 weeks after PCV15 (but not after PCV20)

-if previous PPSV23- give either PCV15 or PCV20 at least 1 yr later

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16
Q

Herpes Zoster

A

RZV (shingrix) for immunocompromised adults >19y- 2 doses separated by 2-6 months

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17
Q

Vaccines for household members

A

-no live flu vaccine
-some other live are ok (MMR) while others are not (polio)

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18
Q

Vaccine during ICI therapy

A

No live

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19
Q

Covid vaccines

A

-Prefer mRNA (Pfizer/Moderna for primary series
-3 dose series for: tx of hematologic ca, organ transplant, CAR-T, HIV, steroids
-no need to delay following antibodies
->3 months after HCT/CAR-T
-no need to delay after mabs
-if heme-chemo wait til ANC recovers
-separate from surgery by a few days
-for solid tumor chemo just vaccinate when vaccine available
-4 wks before or 6 months after B cell therapy
-2 wks before immunosuppressive therapies
-don’t give Evusheld for at least 2 weeks after

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20
Q

Low v high risk FN

A

Low: MASCC >/=21, CISNE<3, talcotts group 4

High: MASCC<21, CISNE >/=3, talcotts 1-3

-assess MASCC and Talcotts first- if low risk proceed to CISNE to confirm only if pt has a solid tumor and had chemo recently

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21
Q

Proteosome inhibitor: ppx

A

VZV ppx

22
Q

BTK inhibitors: Ppx

A

Acalabrutinib, ibrutinib, zanubrutinib

Consider pjp and VZV if additional risk factors

23
Q

PI3K inhibitors: ppx

A

Copanlisib, idelalisib

-consider pjp
-monitor for cmv reactivation

24
Q

JAK inhibits ppx

A

Ruxolitinib

-consider pjp, hsv, VZV
-screen/tx hep b and TB

25
Q

IDH1 and IDH2 inhibitors

A

Enasidenib, ivosidenib

Differentiation syndrome may be difficult to distinguish from infection

26
Q

FLT3 inhibitors inhibitors ppx

A

Gilteritinib, midostaurin

Differentiation syndrome may be difficult to distinguish from infection

27
Q

CD19/CD3 mAb

A

Blinatumumab

-consider pjp, hsv, vzv

28
Q

CD20 mAb

A

Obinutuzumab, ofatumumab, rituximab

-consider hsv/VZV ppx
-consider pjp if other risk factors
-screen/tx hep b

29
Q

CD30 mAb

A

Brentuximab vedotin

-consider pjp, hsv, and VZV
-monitor for cmv reactivation

30
Q

CD38 mAb

A

Daratumumab

-hsv/ vzv
- consider pjp

31
Q

CD52 mab

A

Alemtuzumab

-pjp if CD4<200
-hsv, vzv
-monitor for cmv reactivation
-screen/tx hep b and TB

32
Q

BRAF kinase inhibitors

A

Dabrafenib, encorafenib, vemurafenib

May develop drug fever

33
Q

MEK inhibitors

A

Cobimetinib, trametinib

May develop drug fever

34
Q

Hep B

A

-ppx for and HBsAg+ or HBcAb+
-Ppx with entecavir or tenofovir (lamivudine less preferred)during cancer therapy and for 12 months after
-for people with past infxn just monitor HBsAg and ALT during therapy

Note: so you can still treat the pt, just need to add ppx

35
Q

Cdif

A

Initial:
FDX 200 mg po bid x 10d or VAN 125 mg po Q6h x10d

Initial fulminant:
VAN 500 po Q6h + MTZ 500 mg IV q8 h (consider rectal VAN if ileus)

Recurrent/subsequent:
-FDX or
-VAN tapered and pulsed
-could add bezlotoxumab
-consider fecal microbiota transplant

36
Q

Regimens with >20% risk of FN

A

Bladder:
DD-MVAC

Bone:
-VAI
-VDC-IE
-VDC
-VIDE
-cisplatin doxorubicin

Breast:
-DD- AC —>DD—>paclitaxel
-TAC (doc + dox + cyclo)
-TC (doc + cyclo)
-TCH (doc + carbo + trastuzumab)

Head/neck
-TPF (doc + cis + 5FU)

Hodgkin’s
-Brentuximab +AVD (dox + Vinblastine + Dacarbazine)
-BEACOPP

Kidney
-dox + gemzar

Non-Hodgkin’s
-Brentuximab + CHP (cyclo + dox + pred)
-dose adjusted EPOCH
-ICE (ifos + carbo + etop)
-DD-CHOP
-MINE (Mesna + ifos + mitoxantrone + etop)
-DHAP (dex + cis + Cytarabine)
-ESHAP (etop + Methylprednisolone + cis + Cytarabine)
HyperCVAD: cyclo + vin + dox + dex

Melanoma
-Dacarbazine + IL-2

Multiple myeloma
-DT-PACE: (dex + thalidomide + cisplatin + dox + cyclo + etop)

Ovarian
-topotecan
-docetaxel

Soft tissue sarcoma
-MAID: (Mesna + dox + ifos + Dacarbazine)
-dox
-ifos + dox

Small cell lung cancer
-topotecan

Testicular:
-VeIP: Vinblastine + ifos + cisplatin)
-VIP: etop + ifos + cisplatin
-TIP: pacli + ifos + cisplatin

37
Q

When do we do FN ppx for pediatrics

A

Levofloxacin for pts with AML or relapsed ALL with anticipated nadir to <500 for 7 days or more

38
Q

How long to continue ABX for in FN?

A

Below is for fever of unknown etiology!! For known infxn you tx for appropriate duration of that infxn

Afebrile x48h and ANC>500

*emerging data that can stop if afebrile for several days but ANC not yet recovered

39
Q

Tx of candida in non-neutropenic pts ?

A

Candidemia or invasive candidiasis: Echinocandin is gold standard

40
Q

Tx of candida in Neutropenia pts?

A

Candidemia: Echinocandin is gold standard also

Invasive candidiasis: Echinocandin or liposomal ampho B

41
Q

When should mold coverage be added for rx of FN?

A

After 4 days of persistent fever

42
Q

Which vaccines should cancer pts get?

A

Influenza, pneumococcal, and HZV (shingrix) if 19+

43
Q

Vaccines with immunotherapy

A

Inactivated okay but no live (lack of data)

44
Q

FN indications for vanc

A
  1. HD instability
  2. MRSA colonized or PCN/ceph resistant pneumococci
  3. G+ blood cx
  4. PNA
  5. SSTI
  6. CVAD
45
Q

Meaning of each hep b marker

A

HBsAB+: protective immunity: Limited value due to hep B vaccine

HBsAg+: chronic hep b infxn

HBcAB+: past hep b infxn

46
Q

When to consider G-CSF for therapeutic use

A

double check but I think these require a fever

-expected neutropenia >10 days
-profound neutropenia (ANC<100)
-age >65 y
-PNA
-hypotension
-sepsis
-uncontrolled primary dx
-invasive fungal infection
-hospitalized at fever onset
-prior FN episode
-if pt received ppx G-CSF

47
Q

BTK-I vaccine requirement

A

Zoster

Note: CLL also need flu, pneumococcal, and Covid vaccines- but they often have poor response to vaccines

48
Q

Duration of ABX for infections tx

A

-Most things are 5-14days
-MRSA- 4 weeks after clear cxs
-fungal
-candida- 2 weeks after clear cxs
-mold- 12 weeks
-HSV/VZV- 7-10 days
-flu- 5 days maybe more

49
Q

Mold therapy if drug interaction with azole

A

Ampho B

50
Q

CAR-T

A

-Pjp ppx AND HSV/VZV ppx x1 year
-consider antibacterial and antifungal ppx while neutropenic
-consider mold ppx if additional risk fxs
-screen/tx HBV and TB

51
Q

Positive galactomannan antigen assay

A

Aspergillus

52
Q

Who is expected to have neutropenia that lasts greater than 7 days?

A

Chemo for hematologic malignancy or conditioning regimens for HCT

Chemo for solid tumors is usually neutropenic for less than 7 days

bcop- joey (10 decks)

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