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45 Cards in this Set
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neutropenia definition
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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)
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neutropenia predictors of infection (2)
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Rate of decline and duration of neutropenia are important predictors of infection
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ANC = (equation)
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WBCtotal = [(%segs + %Bands) /100]
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Fever definition (2)
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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 |
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in a neutropenic fever, the source of fever is...
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In a neutropenic patient, the source of fever is infection until proven otherwise
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high risk for complications in NF (3) and do you admit
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Anticipated prolonged neutropenia (greater than 7 days)
Profound neutropenia (less than 100 cells/mm3) And /or significant comorbid conditions hospital admission |
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4 significant comorbidities that bump risk up to high
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Hypotension
Pneumonia New-onset abdominal pain Neurological changes |
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low risk (2)
how to tx |
Short neutropenic periond (less than 7 days)
No or few co-morbidities outpatient oral therapy |
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7 things to do for initial assessment
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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 |
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antiviral therapy not indicated for ...
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Not indicated for empiric use
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manifestations of viral infection and what viruses cause them (3)
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Skin or mucosal lesions- Herpes simplex, Varicella-Zoster
CMV uncommon (BMT patients) Respiratory viral infections- e.g. RSV - ribavirin Influenza A -neuraminidase inhibitors |
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RSV and flu A ppx
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Ribavirin for RSV
neuraminidase inhibitors for flu A |
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3 options for antifungal therapy and when you might give
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if patient doesn't respond to abx therapy
Fluconazole Echinocandin Amphotericin B |
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G-CSF (filgrastim) and GM-CSF (sargramostim) may do what for NF (2)
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may decrease length of neutropenia and
Enhance engraftment in BMT patients |
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studies on filgrastim/sargramostim- does it work? (2)
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Studies fail to find a benefit with use of typical febrile neutropenic episode
No decrease in infection-related mortality |
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when to d/c CSF (filgrastim,etc)
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Discontinue when ANC greater than 500-1,000/mm3
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Indication for use of Colony Simulating Factors- 2 general factors
then 5 specific diseases |
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 |
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filgrastim- dosing/route
dosing based on what weight |
Dose 5-10 mcg/kg (based on actual body wt.) QD
SQ or IV |
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filgrastim/sareaggstratstim storage and administration (2)
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Refrigerate, Do NOT Freeze
Do not shake |
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filgrastim dilute in what
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May be diluted with D5W NOT normal saline
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filgrastim monitoring (2)
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CBC w/platelets, hematocrit
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filgrastim AE (3)
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bone pain, N/V, alopecia
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sargramostin dosing and route
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Dose 250 mcg/m2/day
Administered SC or IV |
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sargramostin- reconstitute and dilution in what
not compatible with what |
Reconstitute with sterile water
May be diluted with NS Not compatible with dextrose containing solns |
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sargramostin monitoring (2)
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CBC with platelets, renal hepatic funxn
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sargramostin AE (3)
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bone pain, N/V, alopecia
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what are granulocyte transfusions
is it used? |
Transfusion of high counts of granulocytes obtained after administration of G-CSF to a donor
Usually not recommended |
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general non pharm measures to take to prevent infection (3)
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Reverse isolation
Proper handwashing by personnel Avoiding fresh fruits and vegetables during neutropenia |
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infection ppx- should you use a lot?
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Avoid antimicrobial prophylaxis if possible
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purpose or infection ppx- thought to do what?
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Prevent translocation of gut flora into bloodstream
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Selective decontamination includes use of what...(2)
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Non-absorbable antibiotics (e.g. bactrim, nystatin...) to select for gut decontamination
Absorbable antibiotics |
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Indication for Antimicrobial Prophylaxis in Afebrile Neutropenic Patients- 2 main conditions
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If ANC less than 100/mm3 for greater than 1 week and ...long list
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9 conditions where you would give ppx in pt who are afebrile
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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 |
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Mucocutanious Candidal infections - ppx (2)
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Nystatin suspension
Clotrimazole troches |
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drug for systemic ppx of fungal
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fluc typically in BMT pop
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aspergillus ppx- recommended?
3 options 1 non pharm option |
Not routinely recommended
Voriconazole Posaconazole Intranasal/aerosolized amphotericin B HEPA filtratoin |
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PCP and HSV ppx
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Trimethoprim/sulfamethoxazole
for PCP hsv acyclovir |
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outpatient NF drug of choice
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PO cipro
+ amox/clav |
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4 options for inpatient IV abx
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empiric broad spectrum
piperacillin/tazo OR carbepenem (broad spectrum- if penicillin allergic) OR ceftazidime OR cefepime (antipseudomonals) |
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abx you can add to IV abx and 3 conditions that you would adjust if not responding
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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 |
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day 2-4 after empirical abx therapy:
high risk with still unexplained fever and negative cultures |
continue abx until ANC greater than 500 and rising.
otherwise just keep watching them. |
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day 2-4 after empirical abx therapy: culture positive
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modify abx for culture results
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day 2-4 after empiric therapy for low risk
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high risk pt with prolonged fever (what is "prolonged"): what do you do
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prolonged = 4+ days
consider fungal infection if not on antifungal- add one if already on one- go broader spectrum (see algorithm) |
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when to give low risk pt hospital IV abx (3)
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documented infection requireing IV abx
GI intolerance pt/physician decision |