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55 Cards in this Set

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Approximately ___% of all febrile neutropenic patients have an established or occult infection.
50
___% of patients with neutrophil counts less than 100cells/mm3 have bacteremia.
20
T/F: The % of G+ organisms causing neutropenic bacteremia is decreasing over time.
FALSE
Why are G+ organisms becoming more predominant in the neutropenic population?
Indwelling catheters, broad spectrum prophylactic treatment that cover G+ provide more G- coverage than G+.
In a neutropenic patient, what simple sign is taken as de facto proof of infection unless proven otherwise?
Fever
According to this lecturer, what is defined as a fever?
Oral temp: 101 OR
100.4 for 1 hour
3 important facts about Neutrophils!
Most frequently occuring WBC
Phagocytic
Very sensitive to myelosuppressive therapy
Why are neutrophils so sensitive to myelosuppressive agents?
Because it takes 14 days to production and differentiation from marrow.
Average time in circulation is 14 hours
Rapid turnover, replaced in blood BID!
Normal Neutrophil range
1800-7800 neutrophils/mm3
How do you calculate ANC (Absolute Neutrophil count)?
ANC=WBC x (%segs/100+%bands/100)
What is Nadir?
THe lowest point of ANC of post chemo
When does Nadir typically occur?
7-14 days after last chemo treatment
What is the normal length of neutropenia?
3-5 days, if greater than 5 considered severe
ANC <1000cells/mm3, classify
Mild risk of infection
ANC <500cell/mm3, classify
Moderate
ANC < 100/mm3 Classify
SEVERE risk of infection
What ANC's are SEVERE risk of infection?
<100
What ANC's are MODERATE risk of infection
<500
What ANC's are Mild risk of infection?
<100
What two factors determine the risk of infection?
ANC + Duration
Besides Duration and ANC, what diseases could also result in increased risk of infection?
Leukemia, lymphoma
ANC cutoff for inpatient
<500
Describe why signs and symptoms during physical examination besides fever maybe unremarkable?
Since the patient is neutropenic, there is no neutrophils to launch an attack on the pathogens so no:
Pyuria in a UTI
No inflammation/Redness in cellulitis
No infiltrates on lung X-ray
No symptoms with meningeal infections
What sign, besides fever, is indicative of infection in a neutropenic patient?
Pain at IV sites, indicating possible catheter related infection.
On the baseline workup, what 7 items should be included?
- >/= 2 blood samples from DIFFERENT SITES
-CXR
-CBC w/ differential
-LFTs
-BMP
-Urinalysis with culture
-Physical Exam (Pain @ IV sites)
2 Major G+ pathogens to worry about
Staph + Viridans Strep
2 Major G- pathogens to worry about
E. Coli
Pseudmonas aeruginosa (hospital)
Which gram type pathogens have 15-70% mortality within one day?
G-
How do you prophylax for PCP?
Bactrim or Dapsone
Thought process for initial empirical therapy
1. Evaluate fever/Neutrophil status
2. Determine risk as inpatient or outpatient
3. Vanco?
Describe guidelines by which we assess which broad spectrum ABx therapy to initiate?
We want adequate G- as a must due to fulminant Pseudomonas aeruginosa. G+ wise we have time on our side.
Outpatient risk status, how many drugs?
2 drugs minimum
Inpatient risk status, how many drugs?
1 or 2 drugs minimum
When should ABx be initiated?
1. Febrile OR
2. ANC <500 or <1000 and trending down AND S/Sx of infection

S/Sx of infection: Abdominal pain, pain on IV flush
OUTPATIENT REGIMEN FOR NEUTROPENIC FEVER
CEFEPIME AND AUGMENTIN (For adults only)
Inpatient Monotherapy regimen for neutropenic fever
Cefepime OR
Ceftazidime OR
Carbapenem (G- Killer)
Inpatient Combination Therapy for Neutropenic fever
Aminoglycoside PLUS
1. Antipseudomonal pcn OR
2. Cefepime OR
3. Ceftazidime OR
4. Carbapenem
Why should Vanco be limited to an indication?
Because G+ infections are usually indolent and we must reserve this agent.
When can Vanco be used empirically?
If a patient presents with specific risk factors:
1. Catheter related infection
2. + culture on G+ pathogen but before susceptibility testing
3. Known colonization with PCN or ceph resistant pathogens MRSA
4. Hypotension or evidence of vascular impairment
5. Substantial mucosal damage from chemo
6. Progression to infection from previously classified low risk or previously prophylaxis with Fluoroquinolone
What should be done after 3 days and the patient is Afebrile? (Re-evaluation)
If pathogen is known, tailor therapy to particular pathogen.
CONTINUE ABX FOR 7 DAYS TO PREVENT BREAKTHROUGH INFECTION.
IT IS PREFERABLE TO HAVE ANC >500 BEFORE D/C ABX
What should be done if a patient is Febrile after 3 days (Re-evaluation)?
Consider:
1. Nonbacterial
2. Resistant Bacterial
3. Slow response
4. Poor serum/tissue levels
5. Second infection
6. Drug fever (Last consideration)
7. Avascular infection
THE PATIENT MAY BE FINE SINCE THE AVERAGE DEFERVESCENCE MAY TAKE 5 DAYS!!!!!
Hey, how many cultures should you do when you assess the patient?
at least 2 draws from different sites!
What should you do if a patient is unresponsive and febrile after 5-7 days of comprehensive broad spectrum antibiotics?
Consider fungal
Two most common fungal pathogens?
Candida and Aspergillus
How long should anti-fungal therapy be continued in absense of S/Sx of infection?
14 days
Gold standard Anti-Fungal
Amp B
Amp B ADR
NEPHROTOXIC, infusion reaction (HypoTN,rigors,N/V)
When CAN Fluconazole be used?
At institutions without drug resistant candida
When should you NOT use fluconazole?
If patients have a suspected aspergillus infection or BMT(bone marrow transplant) patients who received prophylaxis with fluconazole.
General rule of thumb regarding duration of treatment, when should treatment continue
When:
ANC<100 OR
Lesions on mucous membranes/GIT OR
Unstable Vitals
When can Anti-fungal therapy be withdrawn?
After 14 days of therapy AND/OR lesions cannot be found via CT
Way to remember inpatient monotherapy
3 C's
Cefepime or Ceftazidime or Carbapenem
Way to remember outpatient PO?
i CAn leave
C = Cipro
A = Augmentin
Way to remember inpatient combination therapy
A + ACCC
AG + Antipseud PCN/Cefepime/Ceftazidime/Carbapenem
Health care precautions as far as Neutropenic fever
Reverse isolation
Handwashing
Avoid fresh fruits/veggies
Laminal flow hoods to filter away from patient
Well cooked food.