Neutropenic fever Flashcards
(43 cards)
cause of fever in most neutropenic fever patients
endogenous microflora
medication associated with reaction of HSV and VZV
mTOR inhibitors (sirolimus, everolimus)
when ANC is expected to reach nadir with chemo treatment
12 to 14 days from day 1
cancer type in which neutropenic fever is most common
acute leukemia, substantially less common in solid organ
most frequent pathogens in neutropenic fever
gram-positive bacteria (anaerobes infrequent)
what is the term for G-CSF and GM-CSF agents?
colony stimulating factors
what is myeloid reconstitution syndrome?
Onset or progression of an inflammatory focus defined clinically or radiologically temporally related to neutrophil recovery.
evidence for antibiotic prophylaxis for high risk neutropenic patients?
Effective but high NNT, and there are a lot of downsides (cost, side effects, resistance), so should be limited to high risk patients.
risk of fungal infection?
Very low among patients for whom the anticipated duration of neutropenia (ANC <500 cells/microL) is anticipated to be seven days or fewer.
when risk of neutropenia is highest during chemo
typically during the first two cycles of chemotherapy
RF’s for neutropenic events
- age >65 years
- preexisting neutropenia or extensive bone marrow involvement by tumor
- more advanced cancer
- poor performance and/or nutritional status - renal or hepatic dysfunction
Guideline update on use of colony stimulating factors during COVID-19
NCCN and ASCO have lowered the threshold for the use of myeloid growth factors from those chemotherapy regimens which have a 20 percent or higher risk of febrile neutropenia to now include those regimens with a risk of 10 to 20 percent, which includes all of the intermediate-risk chemotherapy regimens.
General term for medications used to
Colony stimulating factors
Why don’t we use CSF’s to treat neutropenic fever?
1) Controversial and mixed results. (no effect on mortality, shorter hospital stays in studies, but also increased rates of side effects).
2) It takes several days for CSF to produce a response with increased circulating neutrophils, so antibiotics work faster.
Neupogen generic name
Filgrastim
neulasta generic name
Pegfilgrastim
optimal duration of GCSF per guidelines
No consensus, guidelines vary
NCCN guidelines suggest daily administration until the post-nadir ANC recovers to normal or near-normal levels by laboratory standards
Why neulasta is typically used
Multiple RCTs and a meta-analysis have shown that pegfilgrastim is at least as effective as and more convenient to administer than G-CSF for primary prophylaxis in patients requiring CSF treatment during myelosuppressive chemotherapy
Potential treatment side effect of CSFs
therapy related myeloid neoplasm (a small but real increased risk of therapy-related myeloid neoplasms (myeloid growth factor receptors are expressed by several hematopoietic and nonhematopoietic cell types)
Risk of complications in neutropenic fever is based on…
duration and severity of neutropenia
When do you modify initial antibiotic regimen?
IF fever persists after 4 days → add antifungal coverage
Positive infectious workup
Hemodynamic instability
*NOT for persistent with negative workup
when people are at increased risk of fungal infections
- prolonged duration of neutropenia (more than 7 days of persistent neutropenia)
- comorbidities
how long do you continue abx?
Discontinue once myeloid reconstitution (ANC>500) + afebrile x48h
Evidence for use of CSF’s in neutropenic fever
NOT recommended
