Neutropenic Fever

Front 1

Approximately ___% of all febrile neutropenic patients have an established or occult infection.

Back 1

50

Front 2

___% of patients with neutrophil counts less than 100cells/mm3 have bacteremia.

Back 2

20

Front 3

T/F: The % of G+ organisms causing neutropenic bacteremia is decreasing over time.

Back 3

FALSE

Front 4

Why are G+ organisms becoming more predominant in the neutropenic population?

Back 4

Indwelling catheters, broad spectrum prophylactic treatment that cover G+ provide more G- coverage than G+.

Front 5

In a neutropenic patient, what simple sign is taken as de facto proof of infection unless proven otherwise?

Back 5

Fever

Front 6

According to this lecturer, what is defined as a fever?

Back 6

Oral temp: 101 OR
100.4 for 1 hour

Front 7

3 important facts about Neutrophils!

Back 7

Most frequently occuring WBC
Phagocytic
Very sensitive to myelosuppressive therapy

Front 8

Why are neutrophils so sensitive to myelosuppressive agents?

Back 8

Because it takes 14 days to production and differentiation from marrow.
Average time in circulation is 14 hours
Rapid turnover, replaced in blood BID!

Front 9

Normal Neutrophil range

Back 9

1800-7800 neutrophils/mm3

Front 10

How do you calculate ANC (Absolute Neutrophil count)?

Back 10

ANC=WBC x (%segs/100+%bands/100)

Front 11

What is Nadir?

Back 11

THe lowest point of ANC of post chemo

Front 12

When does Nadir typically occur?

Back 12

7-14 days after last chemo treatment

Front 13

What is the normal length of neutropenia?

Back 13

3-5 days, if greater than 5 considered severe

Front 14

ANC <1000cells/mm3, classify

Back 14

Mild risk of infection

Front 15

ANC <500cell/mm3, classify

Back 15

Moderate

Front 16

ANC < 100/mm3 Classify

Back 16

SEVERE risk of infection

Front 17

What ANC's are SEVERE risk of infection?

Back 17

<100

Front 18

What ANC's are MODERATE risk of infection

Back 18

<500

Front 19

What ANC's are Mild risk of infection?

Back 19

<100

Front 20

What two factors determine the risk of infection?

Back 20

ANC + Duration

Front 21

Besides Duration and ANC, what diseases could also result in increased risk of infection?

Back 21

Leukemia, lymphoma

Front 22

ANC cutoff for inpatient

Back 22

<500

Front 23

Describe why signs and symptoms during physical examination besides fever maybe unremarkable?

Back 23

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

Front 24

What sign, besides fever, is indicative of infection in a neutropenic patient?

Back 24

Pain at IV sites, indicating possible catheter related infection.

Front 25

On the baseline workup, what 7 items should be included?

Back 25

- >/= 2 blood samples from DIFFERENT SITES
-CXR
-CBC w/ differential
-LFTs
-BMP
-Urinalysis with culture
-Physical Exam (Pain @ IV sites)

Front 26

2 Major G+ pathogens to worry about

Back 26

Staph + Viridans Strep

Front 27

2 Major G- pathogens to worry about

Back 27

E. Coli
Pseudmonas aeruginosa (hospital)

Front 28

Which gram type pathogens have 15-70% mortality within one day?

Back 28

G-

Front 29

How do you prophylax for PCP?

Back 29

Bactrim or Dapsone

Front 30

Thought process for initial empirical therapy

Back 30

1. Evaluate fever/Neutrophil status
2. Determine risk as inpatient or outpatient
3. Vanco?

Front 31

Describe guidelines by which we assess which broad spectrum ABx therapy to initiate?

Back 31

We want adequate G- as a must due to fulminant Pseudomonas aeruginosa. G+ wise we have time on our side.

Front 32

Outpatient risk status, how many drugs?

Back 32

2 drugs minimum

Front 33

Inpatient risk status, how many drugs?

Back 33

1 or 2 drugs minimum

Front 34

When should ABx be initiated?

Back 34

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

Front 35

OUTPATIENT REGIMEN FOR NEUTROPENIC FEVER

Back 35

CEFEPIME AND AUGMENTIN (For adults only)

Front 36

Inpatient Monotherapy regimen for neutropenic fever

Back 36

Cefepime OR
Ceftazidime OR
Carbapenem (G- Killer)

Front 37

Inpatient Combination Therapy for Neutropenic fever

Back 37

Aminoglycoside PLUS
1. Antipseudomonal pcn OR
2. Cefepime OR
3. Ceftazidime OR
4. Carbapenem

Front 38

Why should Vanco be limited to an indication?

Back 38

Because G+ infections are usually indolent and we must reserve this agent.

Front 39

When can Vanco be used empirically?

Back 39

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

Front 40

What should be done after 3 days and the patient is Afebrile? (Re-evaluation)

Back 40

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

Front 41

What should be done if a patient is Febrile after 3 days (Re-evaluation)?

Back 41

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!!!!!

Front 42

Hey, how many cultures should you do when you assess the patient?

Back 42

at least 2 draws from different sites!

Front 43

What should you do if a patient is unresponsive and febrile after 5-7 days of comprehensive broad spectrum antibiotics?

Back 43

Consider fungal

Front 44

Two most common fungal pathogens?

Back 44

Candida and Aspergillus

Front 45

How long should anti-fungal therapy be continued in absense of S/Sx of infection?

Back 45

14 days

Front 46

Gold standard Anti-Fungal

Back 46

Amp B

Front 47

Amp B ADR

Back 47

NEPHROTOXIC, infusion reaction (HypoTN,rigors,N/V)

Front 48

When CAN Fluconazole be used?

Back 48

At institutions without drug resistant candida

Front 49

When should you NOT use fluconazole?

Back 49

If patients have a suspected aspergillus infection or BMT(bone marrow transplant) patients who received prophylaxis with fluconazole.

Front 50

General rule of thumb regarding duration of treatment, when should treatment continue

Back 50

When:
ANC<100 OR
Lesions on mucous membranes/GIT OR
Unstable Vitals

Front 51

When can Anti-fungal therapy be withdrawn?

Back 51

After 14 days of therapy AND/OR lesions cannot be found via CT

Front 52

Way to remember inpatient monotherapy

Back 52

3 C's
Cefepime or Ceftazidime or Carbapenem

Front 53

Way to remember outpatient PO?

Back 53

i CAn leave
C = Cipro
A = Augmentin

Front 54

Way to remember inpatient combination therapy

Back 54

A + ACCC
AG + Antipseud PCN/Cefepime/Ceftazidime/Carbapenem

Front 55

Health care precautions as far as Neutropenic fever

Back 55

Reverse isolation
Handwashing
Avoid fresh fruits/veggies
Laminal flow hoods to filter away from patient
Well cooked food.