FN (febrile neutropenia)

how to find absolute neutrophil count (ANC)?

• (% segs + % bands)/100 x 1WBC

• %neutrophils x WBC

what is nadir

• lowest level of blood counts during chemotherapy cycle (ANC or platelets)

what is the usual onset for Nadir?

a) 7 days post chemotherapy

b) 10-14 days post chemotherapy

c) 14-21 days post chemotherapy

d) 3 days post chemotherapy

b) 10-14 days post chemotherapy

absolute ANC

• ANC < 1000

• or expected decline to <500 cells/mm3 within 48 hours

prolonged neutropenia is when >/=___ days

7

severe ANC is when ANC is <_____ cells/mm3

• <500 cells/mm3

what are the 2 conditions required to have febrile neutropenia

1. ANC <500 cells/mm3 (severe ANC)

2. single temp >101F or 2 consecutive temperatures >/=100.4F in a 12-hour period for >/= 1 hour

FN risk factors

• patient-related

  • >65 yrs old

  • poor performance status

  • pre-existing neutropenia (<100)

  • recent surgery / infections

• treatment-related / cancer-related

  • previous chemo/radiation

  • cancer stage

T/F: most often, neutropenic fevers yield microbiologic responses

• false

  • only 10-30% of fevers yield microbiologic responses

what type of empiric coverage is used for FN

• gram positive bacteria & gram negative bacteria (i.e. Pseudomonas)

when do you end broad spectrum treatment?

*use whatever is LONGER

1. NO confirmed infection (afebrile + ANC >/=500) OR

2. until confirmed infection = treated (guidelines based)

when do you start broad-spectrum antibiotic therapy?

a) initiate with 3 hours of fever spike, after 2 sets of BCxs have been drawn

b) initiate with 5 hours of fever spike, after 1 set of BCxs have been drawn

c) initiate with 1 hour of fever spike, after 2 sets of BCxs have been drawn

d) initiate with 1 hours of fever spike, after 1 set of BCxs have been drawn

c) initiate with 1 hour of fever spike, after 2 sets of BCxs have been drawn

inpatient empiric antibiotic treatment options

• cefepime

• pip/tazo (Zosyn)

• carbapenems (except ertapenem)

what carbapenem is NOT used for inpatient antibacterial empiric coverage?

a) meropenem

b) doripenem

c) imipenem

d) ertapenem

d) ertapenem

what fluoroquinolone is NOT used for outpatient antibacterial empiric coverage?

a) ciprofloxacin

b) levofloxacin

c) moxifloxacin

d) delafloxacin

c) moxifloxacin

outpatient empiric antibiotic treatment options

• amoxicillin-clav (Augmentin) + fluoroquinolone (except moxifloxacin)

• monotherapy FQ

• clindamycin (used for penicillin allergy)

• cefpodoxime (FQ allergy; no pseudo coverage though)

is empiric vancomycin treatment recommended?

• NO

  • no reduction in fever / mortality

when is vanco empiric treatment recommended?

• waiting for MRSA swab / +BCx for gram-positive bacteria

• known colonization

• hemodynamic instability

when do you initiate empiric antifungal therapy?

• high risk patients with persistent fever after 4-7 days of broad-spectrum antibiotics / neutropenia >7 days

when do you initiate empiric antiviral therapy?

• if clinical/lab evidence of viral disease

empiric antifungal treatment options

• echinocandins

• azoles

• amphotericin B

when to start FN prophylaxis ?

• ANC < 500 cells/mm3 with NO fever requirement

• antimicrobial agents only for high-risk patients

how long to keep FN prophylaxis?

• until ANC >/= 500 cells/mm3

what agent is used for FN bacterial prophylaxis?

a) carbapenems

b) 3rd gen cephalosporins

c) fluoroquinolones

d) vancomycin

c) fluoroquinolones (except for moxifloxacin)

T/F: CSF can be used for FN treatment

• false

how is Filgrastim dosed?

• weight based

  • 5 mcg/kg/day

• given daily (short-acting)

when to initiate Filgrastim?

• within 24-72 hours after chemotherapy

SATA: which of the following CSF has “self-regulation”?

a) filgrastim

b) pegfilgrastim

c) efapegrastim

d) sargramostim

b) pegfilgrastim

c) efapegrastim

which of the following CSF is weight-based?

a) filgrastim

b) pegfilgrastim

c) efapegrastim

d) sargramostim

a) filgrastim

how is pegfilgrastim dosed?

• given once per cycle (>/= 14 days before next cycle)

when can you use CSF for FN prophylaxis?

• chemotherapy regimens causing >/= 20% incidence of FN

CSF prophylaxis is generally not recommended in ______ _______

• myeloid malignancies

  • can stimulate cancer cells trying to treat

what is the major adverse effect of CSF?

• bone pain

  • long-bone pain from histamine release

what agent is used to help alleviate bone pain from CSF?

a) H1-inhibitors

b) APAP

c) NSAIDs

a) H1-inhibitors