L7 - Febrile Neutropenia

What are neutrophils?

Type of white blood cell (WBC) and an essential component of the innate immune system

What is the function of neutrophils?

All of the above

Absolute Neutrophil Count Calculation:

Which of the following BEST defines severe neutropenia?

ANC < 500 cells/µL or ANC < 1000 cells/µL and predicted to decline to 500 cells/µL or less over the next 48 hours

What is the association between neutropenia and infection risk?

The risk of infection INCREASES with the degree and duration of neutropenia

Infection risk is HIGHEST in those with .....

Profound and Prolonged neutropenia

Which of the following patient populations are at the HIGHEST risk of infection due to profound and prolonged neutropenia?

All of the above

What is FEBRILE neutropenia?

Severe neutropenia (ANC

True or False:

Febrile neutropenia is considered a medical emergency

True

Neutropenia is a common complication in patients receiving ....

Cancer therapy

Which of the following patient populations has the HIGHEST incidence of febrile neutropenia?

Patients with hematologic malignancies (80%) and patients with solid tumors (10-15%)

Which of the following factors predispose patients to infections?

All of the above

Neutropenia is the effect of cytotoxic chemotherapy on ______

Hematopoietic progenitor cells

What is the most important risk factor for infection?

Neutropenia

Mucosal Barrier Injury is the effect of cytotoxic chemotherapy on ______

Epithelial cells of the mouth and gastrointestinal tract (manifests as mucositis)

Which of the following best describes dysbiosis in patients receiving chemotherapy?

Alteration of gut microbiota due to chemotherapy, total-body irradiation, or antimicrobial use, leading to colonization with organisms such as Pseudomonas aeruginosa and yeast overgrowth.

Infectious etiology is identified in only 40-50% of cases. Most infections are caused by .....

Endogenous flora

What are the predominant pathogens that cause neutropenia?

Gram-positives and Gram-negatives (pseudomonas)

_________ are late causes of infection in severely immunocomprimsed hosts

Fungi

_______ is usually the first and ONLY sign of infection. However, classic signs of infection may be absent due to impaired inflammatory response

Fever

Fever, in the setting of neutropenia, is considered a sign of ________, until proven otherwise

Infection

What are the types of infections?

All of the above

Which of the following best describes a LOW-RISK patient with febrile neutropenia?

Patient with a SOLID tumor and neutropenia lasting less than 7 days

Which of the following best describes a HIGH-RISK patient with febrile neutropenia?

Patient with a HEMATOLOGIC MALIGNANCY and neutropenia lasting ≥7 days

High-risk patients require ....

Hospitalization and IV antimicrobials

Low-risk patients may be treated in the out-patient setting with PO or IV antimicrobials IF no logistical barriers are present, such as:

All of the above

What are the principles of antimicrobial therapy?

1. Fever in a patient with neutropenia from cancer, should be assumed to be due to infection, until proven otherwise

2. Patients should be assessed soon (within 15 minutes) after presenting after febrile neutropenia

3. First-dose of empiric antimicrobial(s) should be administered within 60 minutes

4. Empiric antimicrobial regimens should always cover pseudomonas aeruginosa

Which of the following is the recommended initial empiric antibiotic therapy for HIGH-RISK patients with febrile neutropenia?

IV antipseudomonal beta-lactam monotherapy

Which of the following IV antipseudomonal beta-lactams can be used as empiric monotherapy in HIGH-RISK febrile neutropenia?

1. Piperacillin/Tazobactam

2. Cefepime

3. Meropenem

4. Imipenem/Cilastatin

Which of the following antibiotics lacks anaerobic coverage and may require the addition of metronidazole in patients with febrile neutropenia and abdominal pain?

Cefepime

Which of the following antibiotic classes is PREFERRED for empiric treatment of high-risk febrile neutropenia in patients colonized with ESBL-producing Enterobacterales?

Carbapenems

Which of the following is TRUE regarding empiric antibiotic selection in high-risk febrile neutropenia patients presenting with abdominal pain or diarrhea?

An antibiotic regimen with anaerobic activity should be selected.

_______ is NOT recommended as a standard part of the initial antibiotic regimen, and is only considered ONLY for specific clinical indications

Vancomycin

Which of the following explains why vancomycin is NOT routinely recommended as part of initial empiric therapy for febrile neutropenia?

All of the above

Which of the following are indications for the addition of vancomycin in HIGH-risk patients?

1. Colonization with MRSA or penicillin-resistant streptococcus pneumoniae

2. Skin and soft-tissue infections

3. Pneumonia

4. Suspected IV catheter-related infection

5. Blood cultures positive for gram-positive bacteria before final identification and susceptibilities

6. Clinical instability (e.g. hypotension, shock)

Which of the following is the preferred oral antibiotic regimen for LOW-RISK patients with febrile neutropenia?

Ciprofloxacin + Amoxicillin/Clavulanate

Which of the following best describes the initial management of LOW-RISK patients with febrile neutropenia?

Administer the first dose of IV antibiotics in a medical facility, observe for ≥4 hours, and transition to an oral fluoroquinolone-based regimen upon discharge.

Which of the following patients should NOT receive an oral fluoroquinolone-based empiric regimen for low-risk febrile neutropenia?

Patients who previously received fluoroquinolone prophylaxis

Which of the following fluoroquinolones provide antipseudomonal coverage?

Ciprofloxacin and Levofloxacin

Which of the following best describes IV antimicrobial selection for LOW-RISK patients with febrile neutropenia?

The initial IV antimicrobial choice is similar to that used for high-risk patients. (pip/tazo, cefepime, meropenem, imipenem/cilastatin)

In HIGH-RISK patients with febrile neutropenia, when can empiric vancomycin be discontinued if no resistant gram-positive organisms are identified?

After 48 hours

Which of the following is the recommended approach for HIGH-RISK patients with febrile neutropenia who become hemodynamically unstable?

Broaden the antimicrobial regimen

In HIGH-RISK patients with febrile neutropenia, empiric antifungal therapy with activity against molds should be considered after how many days of persistent fever?

4-7 days

Which of the following statements regarding follow-up therapy for febrile neutropenia is TRUE?

Empiric antifungal therapy may be considered in high-risk patients with persistent fever lasting 4-7 days.

Which of the following best describes the recommended duration of antibiotic therapy for patients with microbiologically or clinically documented infections during febrile neutropenia?

Continue antibiotics until a standard course of therapy is completed AND ANC is ≥500 cells/µL.

Which of the following describes one approach to discontinuing antibiotic therapy in patients with febrile neutropenia and fever of unknown origin (no identified infection source)?

Continue antibiotics until the patient is afebrile for ≥2 days AND ANC is ≥500 cells/µL and increasing.

Which of the following is an alternative approach to discontinuing antibiotic therapy in patients with febrile neutropenia and fever of unknown origin?

Discontinue antibiotics after ≥3 days of IV therapy if the patient has been afebrile for ≥2 days, regardless of ANC recovery.

Which of the following is TRUE regarding antibiotic duration in patients with febrile neutropenia and fever of unknown origin?

Antibiotics may be discontinued before ANC recovery if the patient has received ≥3 days of IV antibiotics and remained afebrile for ≥2 days.