Phar 352 - Febrile Neutropenia

Front 1

What is the definition of "Neutropenia"?

Back 1

ANC<1.5 x10^9/L

Front 2

What is the definition of "Severe Neutropenia"?

Back 2

ANC<0.5x10^9/L

Front 3

What is the ANC?

Back 3

Absoulte Neutrophil Count = (%neutrophil +%bands) xWBC

Front 4

What are the risk factors of Febrile Neutropenia? (4)

Back 4

1) ANC<1.5x10^9/L

2) Duration of Neutropenia

3) Central Venous Catheters (CVC)

4) Foley Catheters (i.e. urinary catheters)

Front 5

What are the goals of therapy for Febrile Neutropenia? (5)

Back 5

1) Decrease Mortality

2) Prevent complications (e.g. Sepsis and Septic Shock)

3) Decrease morbidity from infection

4) Normalize signs and symptoms

5) Minimize ADRs from medications

Front 6

How do we diagnose Febrile Neutropenia? (5)

Back 6

1) Complete Physical Exam

2) Complete Blood Count & Differential

3) Blood cultures (2 sets)

4) Urine Culture

5) Chest X-ray and CT scan

Front 7

What are the preventitive measures of Febrile Neutropenia? (4)

Back 7

1) Hand washing

2) No fresh flowers and plants in patient rooms 3) Filtered air positive pressure rooms

4) Avoid Raw foods or Unwashed foods

Front 8

What are the likely pathogens for Febrile Neutropenia?

Back 8

Most caused by microorganisms that have colonized the patient at or near the site of infection; Bacteria>60%

1) Gram +ve cocci

2) Gram -ve rods

3) Anaerobes

Front 9

What are the characterisitcs of a "low risk" patient of Febrile Neutropenia? (9)

Back 9

1) Duration of Neutropenia<7 days

2) Resolution of Neutropenia expected <10 days

3) Adults 19-60 years of age

4) Vital signs are stable

5) Temp<39

6) No focal findings of infection (i.e. Normal CXR)

7) No chronic lung disease or diabetes

8) No history of fungal infection

9) No IV catheter site infection

Front 10

What is the recommended drug therapy for "low risk" of Febrile Neutropenia patients?

Back 10

Amoxicillin-Clavulonate (500mg PO TID) + Ciprofloxacin (750mg PO BID)

Front 11

What is the recommended drug therapy for "high risk" of Febrile Neutropenia patients?

Back 11

1) Piperacillin/ Tazobactam IV

2) Ceftazidime IV

3) Cefepime IV

4) Imipenem/ Meropenem IV

Front 12

When is Imipenem/Meropenem used for Febrile Neutropenia?

Back 12

Reserved for patients worsening/septic shock/being transferred to ICU

Front 13

When would you add Aminoglycoside to initial therapy? (5)

Back 13

1) If gram -ve bacteremia

2) If the source is Pneumonia

3) If there are unstable vital signs

4) If the patient is experiencing septic shock

5) Documented Pseudomonas infection

{e.g. Tobramycin, Gentamicin, Amikacin}

Front 14

When would you add Vancomycin to Aminglycoside +Initial therapy? (4)

Back 14

1) If clinically obvious CVC infections

2) If suspected or confirmed gram +ve organisms

3) If known colonization with MRSA

4) If the patient has hypotension and/or septic shock

Front 15

When would you discontinue Vancomycin?

Back 15

On day 3-5 if the cultures are negative for Beta Lactam resistant gram(+ve) organisms

Front 16

When would you add Metronidazole to Vancomycin+AMG+Initial Therapy?(2)

Back 16

1) Abdominal symptoms/focus

2) Suspected and known C.difficle infection

Front 17

When would you add Antifungals to Metronidazole+Vancomycin+AMG+Initial Therapy?

Back 17

1) If the patient is still febrile for 96 hours AFTER starting antibiotics

{e.g. Amphotericin B, Liposomal AmB, Voriconazole, Caspofungin/Micafungin}

Front 18

When would you add Antiviral Therapy to Antifungals+Metronidazole+Vancomycin+AMG+Initial Therapy?(1)

Back 18

1) If there is evidence of a viral infection

Front 19

What is G-CSF?

Back 19

Granulocyte Colony Stimulating Factor

Front 20

When would you add G-CSF to Antivirals+Antifungals+Metronidazole+Vancomycin+AMG+Initial Therapy?(1)

Back 20

1) If documented infection, neutropenic & not responding to Antibiotics

Front 21

When would you discontinue G-CSF?

Back 21

When ANC >1x10^9/L

Front 22

What is the duration of therapy for Febrile Neutropenia?(3)

Back 22

Continue Antibiotics untill:

1) Afebrile>48hs

2) ANC>0.5x10^9/L

3) If the bug has been identified then 10-14 days total

4) If the bug has not been identified then review daily

Front 23

What are the efficacy monitoring parameters for Febrile Neutropenia? (5)

Back 23

1) Blood cultures (daily)

2) Temp (q4h)

3) HR, BP, RR (q4h)

3) CBC + diff (daily)

4) Clinical Signs

Front 24

What are the safety monitoring parameters fro Febrile Neutropenia? (4)

Back 24

1) SCr, Urea (daily)

2) Urine Output (daily)

3) Rash

4) Aminoglycoside levels