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32 Cards in this Set
- Front
- Back
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What are the risk factors for infection?
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Neutropenia (severity, duration)
Immune system defects (lymphoma, hypogammaglobulinemia, asplenia) Loss of protective barriers (Mucositis - mucosa is a barrier for infection - chemo thins it out, Venipuncture/IV catheter, Urinary catheter, surgery, intubation) Environmental contamination Alteration of microbial flora (hospitalization - flora changes to more gram (-), antibiotic use), Nutrition |
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What are the signs/symptoms of infection?
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Fever (Temp > 38 C)
Pus, abscesses Pain, inflammation at infection site CXR infiltrate |
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Prophylaxis with antibiotics doesn't make you high risk for infection, but if you did get an infection it would likely be with a resistant organism. This is because it changes the flora in your body
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Fever = > 38.3 C (101 F) or 38 C > 1 hour (100.4 F)
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How do you calculate a patients ANC (absolute neutrophil count)?
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ANC = WBC x (percent of segs + percent of bands)
ANC = 0.4 x (0.4 + 0.1) = 0.2 B/L ANC = 200 cells/mm^3 |
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What are the criteria for diagnosis of neutropenic fever?
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Fever and ANC < 500
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What are the likely sites of infection?
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GI tract
Oropharynx Skin (if you have a portocath) Lungs Urine |
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What are the most common pathogens in these patients?
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Most common in neutropenic patients is gram +.
It used to be gram - due to more permanent catheters and prophylaxis use |
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What gram + organisms are likely?
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Staphylococci
Streptococci Enterococci MOST FREQUENT |
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What gram - organisms are likely?
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E. coli, klebsiella, pseudomonas
MOST MORTALITY |
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What fungi are likely?
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Candida
Aspergillus |
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What are the criteria that make a patient low risk?
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Outpatient at time of presentation
No co-morbidities Anticipated duration of neutropenia < 7 days Good performance status No renal or hepatic insufficiency A score > 21 on MASCC Risk Index (Multinational Association of Supportive Care in Cancer) |
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What gram + organisms are likely?
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Staphylococci
Streptococci Enterococci MOST FREQUENT |
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What are your outpatient therapy options?
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Ciprofloxacin 500 mg po q8hr + Augmentin 500 mg po q8hr
Cipro has really good gram - coverage, terrible gram + coverage Dose of cipro is highly than normally seen |
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What gram - organisms are likely?
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E. coli, klebsiella, pseudomonas
MOST MORTALITY |
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What fungi are likely?
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Candida
Aspergillus |
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What are the criteria that make a patient low risk?
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Outpatient at time of presentation
No co-morbidities Anticipated duration of neutropenia < 7 days Good performance status No renal or hepatic insufficiency A score > 21 on MASCC Risk Index (Multinational Association of Supportive Care in Cancer) |
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What are your outpatient therapy options?
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Ciprofloxacin 500 mg po q8hr + Augmentin 500 mg po q8hr
Cipro has really good gram - coverage, terrible gram + coverage Dose of cipro is highly than normally seen |
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What are your options for inpatient therapy - empiric antibiotic Monotherapy?
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Monotherapy
Ceftazidime 2 g IV q8hr Cefepime 2 g IV q8hr Piperacillin-tazobactam 4.6 g IV q6hr Imipepnem-cilastatin 500 mg IV q6hr Meropenem 1 g IV q8hr Know a dose of one of these!!! |
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The most important quality of the antibiotic in the inpatient setting is that it has to cover pseudomonas.
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These are the pseudomonal doses. All patients with febrile neutropenia (inpatient or outpatient) needs pseudomonal coverage.
Cipro covers it in the outpatient setting. |
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What can you add to your inpatient regimen?
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Aminoglycosides - potential synergy (beta-lactams and aminoglycosides), less resistance, BUT added nephrotoxicity
Studies show that monotherapy in uncomplicated patients (not sepsis) is as effective as dual therapy with aminoglycosides - probably wouldn't use it. If the patient is presenting in a more emergent situation you may want to add it. |
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Continuation
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Vancomycin
- Improved gram (+) coverage (ceftazidime has some), BUT selection of vanco resistant organisms, toxicity, monitoring drug levels If the patient has a symptom of gram (+) infection, then you could use it. (IV catheter that is infected, breaks in skin that are infected) |
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When can an inpatient be discharged?
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Neutrophil recovery (ANC > 500 cells x 2 consecutive days)
Afebrile for 48-72 hours No pathogen isolated |
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Selection is based on risk factors, initial signs and symptoms, formulary, antbiogram
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Prompt initiation is essential, preferably within the first hour of presentation.
Continuous assessment is needed. (WBC, Temp, Culturues, Renal Function) |
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What do you do if the inpatient is febrile on day 3?
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No absolute right answer
Patient has been on an antibiotic - could mean a couple of things. Could be no infection - don't stop antibiotics however. Most people would add vanco to cover gram (+). These infections tend to cause low-grade longer infections. If they were hypotensive/tachycardia, you would an amino glycosides Usually 6-7 days need to go by before you add an anti-fungal |
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How do you monitor efficacy and toxicity in antibiotic use?
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Efficacy
- Resolution of symptoms - Afebrile - Clearing of positive cultures - Improved radiologic studies - Serum levels (vanco) Toxicity - Organ function - Allergic reactions |
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Describe the overall treatment algorithm for febrile neutropenic patients.
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Fever + Neutropenia -->
Low Risk --> Oral (Cipro + Augmentin) or IV (you can skip to High risk/No Vanco needed) High Risk --> Vanco not needed (Monotherapy with Cefepime, Ceftazidime, Carbapenem or Dual therapy with those mentioned + aminoglycoside) Vanco needed (Cefepime, Ceftazidime or Carbapenem + Vancomycin +/- Aminoglycoside |
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When do you reassess your antibiotic treatment?
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In 3-5 days
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If the patient is febrile on day 6, what would you do?
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Add an antifungal - Candida is the most common fungus
Second most common is aspergillus |
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What are your anti-fungal choices?
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Amphotericin B
-Desoxycholate -Liposomal -Lipid complex Fine choice - covers all fungi Nephrotoxic however - minimize this with hydration |
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Continuation
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Azole
-Fluconazole -Voriconazole - Excellent anti-fungal, but nephrotoxic IV vehicle. PO voriconzole is fine. -Posaconazole - Downside is a high fat meal is required for adequate absorption - only PO |
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Continuation
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Echinocandins - Very well tolerated but very expensive
-Caspofungin -Micafungin -Anindulafungin |
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If the patient is has renal insufficiency, what would you want to avoid?
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Voriconazole IV
Amphotericin Use an echinocandin You would also want to dose modify the antibiotic regimen you choose. |
