Therapeutics Id Exam 2- Neutropenic Fever

Front 1

neutropenia definition

Back 1

Absolute neutrophil count less than 500/mm3 or 1,000 /mm3 with predicted decline to less than 500 /mm3 (e.g. multiple cycles of therapy, you can look back at previous ANC response to drug)

Front 2

neutropenia predictors of infection (2)

Back 2

Rate of decline and duration of neutropenia are important predictors of infection

Front 3

ANC = (equation)

Back 3

WBCtotal = [(%segs + %Bands) /100]

Front 4

Fever definition (2)

Back 4

Single oral temp of greater than 38.3°C (101 °F)

OR

Oral temp greater than 38.0 °C (100.4 °F) over at least 1 hour

Front 5

in a neutropenic fever, the source of fever is...

Back 5

In a neutropenic patient, the source of fever is infection until proven otherwise

Front 6

high risk for complications in NF (3) and do you admit

Back 6

Anticipated prolonged neutropenia (greater than 7 days)
Profound neutropenia (less than 100 cells/mm3)
And /or significant comorbid conditions
hospital admission

Front 7

4 significant comorbidities that bump risk up to high

Back 7

Hypotension
Pneumonia
New-onset abdominal pain
Neurological changes

Front 8

low risk (2)

how to tx

Back 8

Short neutropenic periond (less than 7 days)
No or few co-morbidities

outpatient oral therapy

Front 9

7 things to do for initial assessment

Back 9

CBC with differential and platelets
Electrolytes, BUN, Scr
Hepatic transaminases
Total bilirubin
Blood cultures (2 sets) a set from each lumen of a multi lumen CVC if pt. has one.
Other cultures as indicated
Chest X ray

Front 10

antiviral therapy not indicated for ...

Back 10

Not indicated for empiric use

Front 11

manifestations of viral infection and what viruses cause them (3)

Back 11

Skin or mucosal lesions- Herpes simplex, Varicella-Zoster
CMV uncommon (BMT patients)
Respiratory viral infections- e.g. RSV - ribavirin
Influenza A -neuraminidase inhibitors

Front 12

RSV and flu A ppx

Back 12

Ribavirin for RSV
neuraminidase inhibitors for flu A

Front 13

3 options for antifungal therapy and when you might give

Back 13

if patient doesn't respond to abx therapy

Fluconazole
Echinocandin
Amphotericin B

Front 14

G-CSF (filgrastim) and GM-CSF (sargramostim) may do what for NF (2)

Back 14

may decrease length of neutropenia and
Enhance engraftment in BMT patients

Front 15

studies on filgrastim/sargramostim- does it work? (2)

Back 15

Studies fail to find a benefit with use of typical febrile neutropenic episode
No decrease in infection-related mortality

Front 16

when to d/c CSF (filgrastim,etc)

Back 16

Discontinue when ANC greater than 500-1,000/mm3

Front 17

Indication for use of Colony Simulating Factors- 2 general factors
then 5 specific diseases

Back 17

If worsening of course predicted and long delay in recovery of marrow and:

pneumonia
Hypotensive episode
Severe cellulitis or sinusitis
Systemic fungal infection
Multi-organ dysfunction secondary to sepsis

Front 18

filgrastim- dosing/route

dosing based on what weight

Back 18

Dose 5-10 mcg/kg (based on actual body wt.) QD

SQ or IV

Front 19

filgrastim/sareaggstratstim storage and administration (2)

Back 19

Refrigerate, Do NOT Freeze
Do not shake

Front 20

filgrastim dilute in what

Back 20

May be diluted with D5W NOT normal saline

Front 21

filgrastim monitoring (2)

Back 21

CBC w/platelets, hematocrit

Front 22

filgrastim AE (3)

Back 22

bone pain, N/V, alopecia

Front 23

sargramostin dosing and route

Back 23

Dose 250 mcg/m2/day
Administered SC or IV

Front 24

sargramostin- reconstitute and dilution in what
not compatible with what

Back 24

Reconstitute with sterile water
May be diluted with NS

Not compatible with dextrose containing solns

Front 25

sargramostin monitoring (2)

Back 25

CBC with platelets, renal hepatic funxn

Front 26

sargramostin AE (3)

Back 26

bone pain, N/V, alopecia

Front 27

what are granulocyte transfusions
is it used?

Back 27

Transfusion of high counts of granulocytes obtained after administration of G-CSF to a donor
Usually not recommended

Front 28

general non pharm measures to take to prevent infection (3)

Back 28

Reverse isolation
Proper handwashing by personnel
Avoiding fresh fruits and vegetables during neutropenia

Front 29

infection ppx- should you use a lot?

Back 29

Avoid antimicrobial prophylaxis if possible

Front 30

purpose or infection ppx- thought to do what?

Back 30

Prevent translocation of gut flora into bloodstream

Front 31

Selective decontamination includes use of what...(2)

Back 31

Non-absorbable antibiotics (e.g. bactrim, nystatin...) to select for gut decontamination
Absorbable antibiotics

Front 32

Indication for Antimicrobial Prophylaxis in Afebrile Neutropenic Patients- 2 main conditions

Back 32

If ANC less than 100/mm3 for greater than 1 week and ...long list

Front 33

9 conditions where you would give ppx in pt who are afebrile

Back 33

Extensive mucous membrane or skin lesions
Presence of indwelling catheters
Instrumentation (i.e., endoscopy)
Severe periodontal disease
Dental procedures
Post-obstructive pneumonia
Malignancy
Organ engraftment
Other immune compromis

Front 34

Mucocutanious Candidal infections - ppx (2)

Back 34

Nystatin suspension
Clotrimazole troches

Front 35

drug for systemic ppx of fungal

Back 35

fluc typically in BMT pop

Front 36

aspergillus ppx- recommended?

3 options

1 non pharm option

Back 36

Not routinely recommended
Voriconazole
Posaconazole
Intranasal/aerosolized amphotericin B

HEPA filtratoin

Front 37

PCP and HSV ppx

Back 37

Trimethoprim/sulfamethoxazole
for PCP

hsv acyclovir

Front 38

outpatient NF drug of choice

Back 38

PO cipro
+ amox/clav

Front 39

4 options for inpatient IV abx

Back 39

empiric broad spectrum

piperacillin/tazo OR
carbepenem (broad spectrum- if penicillin allergic) OR
ceftazidime OR
cefepime (antipseudomonals)

Front 40

abx you can add to IV abx and 3 conditions that you would adjust if not responding

Back 40

vancomycin or linezolid for cellulitis or pneumonia (coverage for gram +)
add AG and switch to carbapenem for pneumonia or gram negative bacteremia
metronidazole for abdominal or c diff suspected

Front 41

day 2-4 after empirical abx therapy:

high risk with still unexplained fever and negative cultures

Back 41

continue abx until ANC greater than 500 and rising.

otherwise just keep watching them.

Front 42

day 2-4 after empirical abx therapy: culture positive

Back 42

modify abx for culture results

Front 43

day 2-4 after empiric therapy for low risk

Back 43

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Front 44

high risk pt with prolonged fever (what is "prolonged"): what do you do

Back 44

prolonged = 4+ days

consider fungal infection

if not on antifungal- add one

if already on one- go broader spectrum (see algorithm)

Front 45

when to give low risk pt hospital IV abx (3)

Back 45

documented infection requireing IV abx
GI intolerance
pt/physician decision