Exam 2

Equations to know for Febrile Neutropenia:

ANC equation

Temperature (F→C) equation

ANC: WBC x {(%segs + %bands)/100} x 1000

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F=C\*9/5 + 32

Define the following:

Febrile

Neutropenia

Severe/prolonged neutropenia

Profound neutropenia

Febrile - fevers: A single oral temp of ≥38.3 C or a temp of ≥38C over a 1 hour period

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Neutropenia: ANC

define the following:

Febrile neutropenia

Nadir

Primary prophylaxis

Secondary prophylaxis

Empiric Therapy

Febrile neutropenia: having both fever and neutropenia

Nadir: lowest point of blood cell line counts.

Primary prophylaxis: Prophylactic antimicrobial dosing to prevent infection in high risk patients

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Secondary prophylaxis: Administering prophylactic doses of an antimicrobial to prevent recurring infection

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Empiric Therapy: Initial broad spectrum treatment

What is myelosuppression

Reduced blood cell counts occurs to a different extent based on the agent used for tx

What is the pathophysiology of neutropenia?

Loss of neutrophils reduces host defense mechanism. Loss of natural barriers and function of leukocytes

When it comes to ANYONE on chemotherapy or having any form of neutropenia we should always consider infection and whether or not we should actively be looking to prophylact. What is one of the ONLY indications that may occur in these patients?

fever -- so avoiding antipyretics and telling them to take fevers seriously is a good choice

What are the 7 factors used to determine a MASCC score:

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Whats a bad number?

Burden of illness (symptom severity)

Hypotension

COPD

Solid tumor or hematologic malignancy w/out prior fungal infection

dehydration

outpatient status

Age

What are the found major steps of febrile neutropenia treatment?

1. patient presenting with fever and neutropenia
2. Start empiric therapy
3. 24-48 hours narrow antibiotic therapy as cultures come back
4. If fever persists at 4-7 days: add antifungal

Define a low risk and a high risk patient toward febrile neutropenia

Low Risk: general good health; out-patient status at fever onset, Brief neutropenia, few or no co-morbidities, stable renal or hepatic function, MASCC score >/= 21

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High risk: inpatient status at time of fever onset, prolonged/profound neutropenia, co-morbidities, hepatic/renal insufficiency, MASCC

Examples of bugs that cause febrile neutropenia:

Gram negatives

MDROs

Gram - : E. coli, Klebsiella, enterobacter, acinebactor,

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MDROs: MRSA, VRE, ESBL GNRs, P aeruginosa

When should you start narrowing and de-escalating empiric therapy in febrile neutropenia

24-48 hours whenever cultures and sensitivities come back

When should anti-fungals be considered for patients considered for febrile neutropenia?

When fever persists for 4-7 days

Empiric therapy options for febrile neutropenia (low-risk) PO therapy options:

1. cipro + augmentin
2. Moxifloxacin
3. Levaquin

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Empiric therapy recommendations for high-risk

* monotherapy (CIMP) and?

Monotherapy:

Cefepime, Imipenem, Merrem, Zosyn

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Add-ons for specific targets like MRSA, antifungals, antivirals, etc.

When should a device not be removed in a case of “central line associated bloodstream infection”?

Coagulase negative \n staphylococci (CoNS)

What precautions should be done in the care of patient’s with febrile neutropenia

washing hands

Protective gear (gloves, down, mask)

NO fresh fruit or flowers due to mold risk

private rooms for stem cell transplant patients

What vaccine precautions should be done for febrile neutropenia patients?

Avoid line vaccines and revaccinating patients that have received transplants

In malignancy, what are some risk factors for opportunistic infections

* Patients factors (age, performance status, nutritional status)
* Underlying diagnosis (blood cancers)
* acute myelogenous leukemia
* acute lymphoblastic leukemia
* Myelodysplastic syndrome
* Treatment:
* P13k inhibitors, proteosome inhibitors, alemtuzumab

Prophylaxis in malignancy: Bacterial prophylaxis


1. who/when
2. Recommended therapy
3. Duration

1. prolonged neutropenia
2. Levaquin
3. \*\* controversial and debated during neutropenia

Prophylaxis in malignancy: antifungal prophylaxis


1. who/when
2. Recommended therapy
3. Duration

1. the HIGH risk patients or prolonged neutropenia
2. Pasoconazole, fluconazole, and micafungin
3. until resolution of neutropenia and/or mucositis

Prophylaxis in malignancy: PCP prophylaxis


1. who/when
2. Recommended therapy
3. Duration

1. high risk patients
2. bactrim is first line


1. atovaquone
2. dapsone
3. pentamidine
3. guidelines dependent

Prophylaxis in malignancy: antiviral prophylaxis


1. who/when
2. Recommended therapy
3. Duration

1. Consider


1. HSV: for patients undergoing stem cell replacement or leukemia induction therapy
2. HBV: for patients with chronic or clinically resolved HBV
2. these:


1. HSV: acyclovir
2. HBV: entecavir or tenofovir
3. until resolution of neutropenia or until 6 months following therapy completion

What are the two readings that an engraftment has been successful?

ANC >500

and platelets >20,000

in the case of pre-engraftment:


1. what factors make the person more susceptible
2. What is this time frame (days?)
3. What are the most likely attackers?

1. increased risk due to neutropenia, mucositis, and acute rejection
2. Encompasses the time during conditioning, HSCT procedure, and prior engraftment
3. Bacteria, fungi, and HSV

in the case of post-engraftment:


1. what factors make the person more susceptible
2. What is this time frame (days?)
3. What are the most likely attackers?

1. increased risk due to impaired cellular immunity, acute/chronic rejection
2. encompasses from first day of engraftment through 100 days later
3. CMV, fungi, mold, and pneumonia

in the case of late phase engraftment:


1. what factors make the person more susceptible
2. What is this time frame (days?)
3. What are the most likely attackers?

1. increased risk due to impaired cellular immunity
2. 100 days +
3. VZV, encapsulated bacteria, fungi, PCP, higher risk in individuals with chronic GVHD

For allogenous HCT prophylaxis, how long should the following durations be?


1. S. pneumoniae prophylaxis
2. antifungal
3. PCP prophylaxis
4. antiviral

1. 3-12 months
2. during neutropenia
3. 3-6 months after transplant
4. during neutropenia and at least 12 months after transplant

How does HIV work?

* what cells are effected
* what system is therefore fucked up?

HIV attacks our body’s T cells


1. CD4 cells are directly attacked, without them CD8 cells cannot be recruited against a pathogen
2. This fucks up the innate immune system

What two factors are used to monitor the progression of HIV in the body?

CD4 counts and viral load

As CD4 counts decrease to the following levels:


1.

1. PCP
2. Toxoplasmosis gondii
3. MAC CMV

Toxoplasma gondii encephalitis:


1. Presentation
2. Diagnostics

1. HA, AMS, weakness, fever, seizures
2. CT of the brain, presence of anti-toxoplasma IgG antibodies, use a lumbar puncture

TE prophylaxis:


1. when to initiate
2. treatment options
3. when to discontinue

1. start when CD4

TE treatment:


1. FIRST LINE
2. back up options
3. how long can you use it

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1. Pyrimethamine + sulfadiazine + leucovorin
2. pyrimethamine + clindamycin + leucovorin OR bactrim
3. 6 weeks of treatment

discontinuation criteria for TE? (3)

1. successful completion of full treatment regimen
2. no signs/symptoms of TE
3. CD4 >200 for atleast 6 months

What makes mycobacterium avium complex (MAC) different from most other bacterial infections?

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What are the 3 types of ways the infection can occur and who does it occur in?

1. it behaves like a mold and primarily spread through respiration

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2. types


1. pulmonary - non-HIV and elderly
2. diseminated - HIV patients
3. lymphadenitis - youth

MAC:


1. clinical presentation
2. diagnostics

1. Fever, night sweats, weight loss, diarrhea
2. Blood culture! (but it shouldn’t delay Tx)

MAC prophylaxis:


1. preferred agents:
2. When can you D/C?

1. Azithro or Clarithro OR rifabutin
2. D/C when patient is stable, 12 months of treatment for MAC, No S/S for MAC disease, CD4 count >100 for ATLEAST 6 months

Treatment for MAC:


1. Preferred agents:
2. Other options
3. duration

1. Clarithro or azithro + ethambutol
2. A/C + E AND rifabutin/aminoglycoside/fluoroquinolone
3. 12 months duration

What should be used for secondary MAC prophylaxis?

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D/C criteria?

1. begins immediately after completing treatment (same regimen as treatment)

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2. completion of 12 months of treatment for MAC disease, NO S/S of MAC disease, CDA > 100 for at least 6 months

CMV disease:


1. Clinical presentation
2. diagnosis via

1. Retinitis, colitis, esophagitis, can cause pneumonea rarely


1. peripheral - floaters, scotomata, visueal defects
2. Central - decreased visual acuity and defects
2. PCR, antigen assay, cultures

CMV:


1. primary prophylaxis
2. secondary prophylaxis


1. when to D/C

1. Primary: NONE but try and maintain a CD4 >100
2. Valganciclovir daily


1. D/C when completion of atleast 3 months of treatment
2. CD4>100 for 3-6 months

CMV disease treatment


1. Retinitis, pneumonitis, and neurological disease
2. Esophagitis or colitis

1. intravitreal **ganciclovir** or **foscarnet + oral valganciclovir**


1. OR intravitreal infections + IV ganiciclovir, foscarnet, or cidofovir
2. IV ganiciclovir then ORAL valganciclovir

Pneumocystis pneumonia (PCP) is caused by what? and when does it occur the most?

Pneumocystis jiroveci

occurs the most in HIV patients without prophylaxis

Diagnostics for diagnosing PCP

Sputum sample is the definitive choice

LDH >500

1,3-B-D-Glucan >80

PCP prophylaxis

* when to start it
* what to start
* when to D/c

* Start when CD4

What are the treatment 5 options for PCP and how long should it go?

1. Bactrim
2. Pentamidine (inhaled)
3. Dapsome + TMP
4. Primaquine + clindamycin
5. atovaquone

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21 days

Vaccinations for patients receiving HSCT guidelines

Post-HSCT consider:

* revaccination
* guidance/avoidance for live vaccines
* COVID

Define invasive fungal infections

Fungal infections that are typically systemic, generalized, deep-seated, and severe (often life-threatening) fungal infections

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How are invasive fungal infections most commonly acquired?

inhalation

Invasive fungal infections include what bugs? (6 of them)

Candida species, aspergillus, mucoroales, histoplasmosis, coccidioidomycosis, blastomycosis

For patients with invasive fungal infections what 3 things MUST WE CONSIDER EVERY TIME?

1. Initially IV until the patient has been stabilized
2. Loading doses are recommended for ALL anti-fungals
3. Remember that ALL systemic anti-fungals may require renal dosing adjustment

Candida is the 4th most common bloodstream infection, what type of candida is most encountered in candidemia?

Candida albicans

Candidemia can manifest in what unique part of the body?

The cornea!

What type of candidemia is a new threat in the drug-resistance world?

Candida auris!

Candidemia incidence at-risk groups include the elderly, immunocompromised, children/neonates, and cancer patients… what strains of candida pertain to each of these groups? What strain related to all of them?

Elderly (>65): Candida glabrata

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Immunocomped: Candida krusei

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Children/neonates: Candida parapsilosis

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Cancer patients: Candida Lusitaniae

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Candida Albicans effects every at-risk group

Invasive fungal infections: When considering when to start treatment and gettings lab results, whats the go to?

The lowest mortality rates occurs when treatment begins with

Blood cultures for invasive candidemia are standard but they can have a 25% of being a false negative. What 3 other tests are doing well and which is looking to be the best?

PNA FISH seems to be the best

MALDI-TOF (Mass spec) is on the risk

And a retinal (fundiscopic exam) are very popular

What type of candida is frequently associated with catheter-associated infections?

Candida parapsilosis

What’s the difference between an STI and an STD

STI: has yet to develop into a disease and does not always develop into a disease

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STD: Result of STI, pathogens have disrupted normal body functions or damaged structures in the body

Who is at risk for an STI/STD:

anyone engaged in sexual activity

Higher risk patients:

* young, multiple partners, MSM, prostitution, illicit drug use

Southeastern united states

If left untreated, STDs can cause what 3 things?

* Increased risk of giving/getting HIV
* Long-term pelvic/abdominal pain
* Inability to get pregnant or pregnancy complications

STI/STD reporting, according to an ohio administrative code, what must be reported?

Conformed or suspected cases of chancroid, chlamydia, gonorrhea, and syphilis to the ohio department of health

What are the 5 P’s of sexual health?

Partners

Practices

Protection

past history

prevention of preganacy

Highest rates of gonorrhea occur in:

1. adolescents and young adults
2. Black race
3. low income
4. lesser education
5. unmarried
6. illicit drug use

What bug causes gonorrhea?

What type of bug is it?

What unique way can it be transmitted?

Neisseria gonorrhoeae

Gram negative buug

Only humans it, can be passed from mom to baby at birth

Where do men and women get infected?

Who are more likely to pass gonorrhea from one to another?

What are some of the symptoms of a gonorrhea infection

urethra for men and vaginal canal for women

Males and MUCH more likely to pass gonorrhea to an uninfected host

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Painful urination, abnormal discharge,

What does disseminated gonorrhea look like?

Present with tender necrotic skin lesions or monoarticular arthritis

RARELY presents as meningitis or endocarditis

What is pelvic inflammatory disease and what most commonly causes it?

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What are the S/S?

Inflammatory disorders of the upper female genital tract

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caused most commonly by gonorrhea

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Pelvic/low and pain, increased vaginal discharge

irregular menstrual bleeding, fever, pain with intercourse

Complications of Pelvic inflammatory disease

Gonorrhea treatment:

What should we advise patients to do after treatment?

What is the recommended regimen for patients with UNCOMPLICATED Gonorrhea? What if Chlamydia is still considered?

What are some alternatives to Ceftriaxone?

1. Patients should abstain from unprotected sex for 7days after they have BOTH completed treatment and symptoms go away. IM ceftriaxone IM is painful
2. Weight based:


1.

How do we treat disseminated gonorrhea and what’s your other option?

Ceftriaxone 1-2g IM or IV every 12-24 hours

Cefotaxime

in the case of gonorrhea expedited partner therapy, what is the treatment for the partner?

Gonorrhea: Cefixime 800mg PO once

Chlamydia: add Doxycycline 100 mg PO BID x7days

expedited partner therapy can be given for what conditions? how many partners?

Chlamydia, gonorrhea, and trichomoniasis

no more than 2 partners

When do we do test of cure for gonorrhea? and when?

What differentiates gonorrhea from chlamydia?

Only for pharyngeal gonorrhea and done 7-14days after treatment

Chlamydia will not disseminate throughout the body

Why isn’t chlamydia seen on a gram stain?

Who should be screened?

What is the recommended test to diagnose chlamydia?

When should a culture be used?

Lacks cell wall peptidoglycan

Sexually active females ≤25, multiple partners, and MSM

NAAT testing is recommended

Use a culture when there is sexual assault or child abuse

How should uncomplicated Chlamydia be treated and what is the alternatives?

Doxy 100 mg BID for 7 days

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Azithro 1g PO once, Levaquin 500 mg PO QD 7days

Patients that are high risk for REinfection, should you retest them?

yes atleast 3weeks to 3 months after treatment

What bug causes syphilis?

What type of bug is it?

Treponema pallidum

A spirochete