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Oncology Exam 2
Frei Febrile Neutropenia (B)
| Question | Answer |
|---|---|
| SH, 59 yo Caucasian female, presented to University Hospital ED with fever, cough, and dizziness • PMH • Stage IIA breast cancer • Lumpectomy • Adjuvant chemotherapy with AC x 4 cycles • Weekly paclitaxel (completed 1of 12 cycles) ROS • +Sore throat, cough, nausea, vomiting, dizzy; Denies abdominal pain, hematuria, dysuria, headaches • Physical exam- ⬇️ breath sounds bilateral bases of lungs; • Vitals (T max- 102.8°F; BP 90/68 mmHg; Pulse- 150 BPM; O2 sat- 97% room air—> action | • Labs (WBC- 0.8 x 109/L; Differential – 15% neutrophils; Hg/Hct - 10.3 g/dl / 31%; Platelets- 120 K cells/mm3; Serum creatinine= 1.2 mg/dl, Blood urea nitrogen; Chemistry, liver function- WNL; HPI (Last chemotherapy cycle 1 week prior)—> ANC? 800 x 0.15–> 120 (Neutropenic) |
| Febrile Neutropenia is? (NEED BOTH) | ANC < 500 /uL or mm^3 PLUS oral temperature > 38.0 (>100.4) Celsius sustained over 1hr or single oral temperature > 38.3 Celsius (101) |
| Why do we care about Febrile Neutropenia? | • FN infections are fatal if not treated appropriately (Mortality rate in 1960’s ≈50%—> Today, with proper management, mortality ≈ 5% • Previously, standard treatment was hospitalization and IV antibiotics • Today, selective low risk pts can be treated outpatient (low risk can be treated at home) |
| Where do these infections come from? Etiology? | • Decreased OR ineffective production (Immune system disorders); • Disruption of membranes (skin, GI, etc.) (Invasion of local flora); • Insults to bone marrow ( Chemotherapy, radiation, surgery); • Invasion (Tumor growth, tumor necrosis) • Clinically documented infections occur in 20-30% of febrile episodes |
| NCCN guidelines say the current time frame when someone comes into the ED for Febrile Neutropenia Management—> | Triage—> w/in 15 min Antimicrobials-> w/in 1 hr Placement—> after 4 hr of observation |
| ***Triage of pt what do we do? | Site specific history and physical; • CBC with differential; • Electrolytes, liver function, renal function; • ***Blood cultures (2 sets of blood cultures from each lumen of existing central line and a peripheral line site if present (IDSA); 2 blood cultures (NCCN)***; • Site specific cultures (burning on urination—> urine sample, sputum for chest x-ray, etc) *get a port sample or catheter sample |
| So if a pt meets the criteria for febrile neutropenia, you start antimicrobial therapy? | First dose within 1 hour of TRIAGE *pts seen in clinic or ED with undetermined risk w/in 1 hr should receive an initial IV dose of therapy while undergoing evaluation |
| For Febrile neutropenia, what anti-pseudomonal B-lactam monotherapy options are there? | ***cefepime. Imipenem-cilastatin, Meropenem, Zosyn*** *b/c they are broad-spectrum |
| So you treated your FN pt with abx, determine severity (do we keep them in hospital or send them home? | -Use MASCC and CISNE score to assess risk of medical complications; (score will be given) |
| Placement by stratification of risk: we can use the MASCC and CISNE score to assess risk of medical complications. What is the Automatic criteria for inpatient? | 1. Infected/colonized with fluoroquinolone-resistant, gram- negative pathogens that are also coresistant to beta-lactams/cephalosporins 2. Colonized with or suspected of having MRSA, VRE, or Stenotrophomonas maltophilia infection 3. Undergoing HSCT (hematopoetic stem cell transplant) or induction therapy for acute leukemia |
| MASCC score: if the MASCC score is 21 or higher (goes up to 26)—> you are going to consider their CISNE score as well to decide if they will be inpatient or outpatient—> | CISNE score 1-2: candidate for outpatient management (assessment and confirmation of pt’s logistic and psychosocial support) CISNE score >/= 3: candidate for inpatient management |
| MASCC score: if the MASCC score is <21–> | Candidate for inpatient management |
| ***Key point on MASCC (Multinational Association of Supportive Care in Cancer) risk index: What is the max score? When is a pt considered low risk? | Max: 26; Low risk is >/= 21*** |
| CISNE (Clinical Index of stable Febrile Neutropenia)—> what score should a pt be managed inpatient? | >/= 3 *because it makes them higher risk of mortality and death |
| The only time when you have to consider CISNE score is when the MASCC score is >/= to? | 21 |
| Management of a pt with febrile neutropenia, we consider? | • Based on placement (outpatient vs inpatient) • Pt specific characteristics (drug allergies, kidney and renal function, ability to swallow) • History of infections • Suspected pathogen |
| What types of microbes and infections are seen in febrile neutropenia? | Most are normal human flora; Bacterial infections most common in 80% of FN pts; Most common pathogens are E. Coli and coagulase (-) Staphylococcus; Fungal infections (incidence is increasing; increased risk with increased duration; Others are viral infections (reactivation of herpes virus; opportunistic pathogens in high risk pts (lymphomas, AIDS, steroids, tx with purine analogs) |
| Gram (+) species are ________ (viridans, pyogenes, pneumonia); _______ (coagulase (-); _________ (emergence VRE) | Streptococcus; Staphylococcus; Enterococcus |
| Gram (-) species are Klebsiella species, E. Coli, and SPICE, which stands for? | Serratia, Pseudomonas, Indole (+) proteus, Citrobacter freundii, Enterobacter |
| ***Management of FN: Treating with outpatient PO therapy, the treatment options are? *This is for low risk— outpatients with MASCC >/= 21 and CISNE < 3 | Cipro + Amox/Clav Or Levo + Amox/Clav |
| ***Management of FN: Treating a high risk pt (MASCC score <21), anyone that has a MASCC score of 21 or over, but has a HIGH CISNE score will get? | Monotherapy with Antipseudomonal B-lactam (Cefepime, Imipenem/Cilistatin, Meropenem, Zosyn |
| ***Antimicrobial additions are ONLY added under SPECIFIC circumstances such as? | suspected catheter-related infection, SSTI, pneumonia, or hemodynamic instability—> add VANCOMYCIN |
| ***Antimicrobial additions: Risk factors for antibiotic-resistant organisms—> add proper coverage for? | MRSA (Vanco, Linezolid, or daptomycin) VRE (Linezolid or daptomycin) ESBLs (carbapenem) KPCs (polymixin-colistin, tigercycline, Ceftazidime-avibactam or Meropenem-vaborbactam) C.Diff (oral vancomycin or Metronidazole) |
| Modifications after initial management for FN pts: | Modifications should be made based on clinical and microbiological data; IV to PO switch should be made if stable and GI absorption is adequate and can swallow oral therapy *question would be what should we do for their abx coverage? Answer would be “narrow therapy to appropriate therapy once something is isolated) |
| ***Duration of Treatment: Fever or no fever? If a pt has afebrile for 48h (no fevers and afebrile is defined as <100.5) PLUS their ANC is over 500 cells/mm^3, we may consider? | stopping abx |
| ***Duration of Treatment: Fever or no fever? If they’re afebrile but their ANC is still too low (<500 cells/mm^3) consider? | stopping AFTER 5-7 days |
| ***Duration of Treatment: Fever or no fever? If they’re still Febrile (ANC is irrelevant)—> action? | still give abx (reassess) |
| ***Duration of Treatment: Fever or no fever? If the cause of FN is known? | NARROW THERAPY and TREAT BASED ON SPECIFIC GUIDELINES |
| ***What are the causes of persistent fever? | -Attempt to identify cause (no change in condition? Continue abx and consider stoppping Vancomycin); -Cancer progression -inadequate response after 5 days with appropriate bacterial coverage (add anti-fungal and consider change in therapy) *anti fungal drugs (i.e. Voriconazole, intraconazole, AMP-B, echinocandins) |
| ***Antifungal therapy: Fungal infections are less common than bacterial infections. These account for majority of infection related deaths. _______ may appear after week 1; ______ may appear after 2-3 weeks; Empiric antifungal tx is typically delayed for ___ days | Candida; Aspergillus; 5 days |
| ***Pts that get the fungal infections fall into these risk factors, such as? | -Hematological malignancies -Cytotoxic chemotherapy -Agents that cause mucosal injury -Prolonged neutropenia (10 days or more) -Broad-spectrum abx |
| When to use MGF in setting of Neutropenia—> Frei told us that there are special circumstances we can use growth factors like Filgrastim when you have febrile neutropenia, but it’s a very special section. The only time we use MGF in FN is if? | They come in already taking MGF and fever was 101, continue giving MGF) |
| If a pt came in with neutropenia with fever and was not taking MGF therapy, then we? | do not give MGF unless pt presents with certain characteristics |
| Pts can use MGF with FN if 1 of the following are present? *high risk of mortality | -Sepsis syndrome -Age > 65 -Severe neutropenia ANC < 100 -Duration of Neutropenia expected to be > 10 days -Pneumonia or clinically documented infection -Invasive fungal infection -Hospitalization at time of fever -Prior episode of FN |
| Summary: FN can be a life-threatening illness (immunocompromised, chemo pts). What do we look for and initiate? | • FN can be a life threatening illness (Immunocompromised, chemotherapy patients) • History and physical (Labs, cultures, scans, etc.) • Determine risk category (low vs. high) • Start empiric antibiotics • Monitor response with ANC and temperature |
| ANC calculate: WBC 2.3 x 10^3 and Segs 45% and Bands 10%—> | 1265 |
| RB a 62 yo female here for Cycle 1 dos (cycle 1 of chemo). No other commorbidities, labs WNL. The risk of FN for this regimen is 23%. Should this pt receive growth factors and if yes, which one? -No -Yes, pegfilgrastim 6 mg once on day after chemo -Yes, filgrastim 5 mcg/kg/day once on day after chemo? -Yes, filgrastim 250 mg/m^2 daily for 5 days starting day of chemotherapy | Yes (since its greater than 20% you automatically give growth factor) *yes, Pegfilgrastim 6 mg once on day after chemotherapy *need to know frequency, its a daily tx, 24-96 hrs -D incorrect, bc starting after chemo and wrong dose -C is incorrect becuase its states “once” not daily; |
| Which of the following as a ADR of pegfilgrastim? -N/V -Hypocalcemia -Diarrhea -Elevated Liver enzymes -Bone pain | Bone pain |
| Correct Abx: Pt 56 yo female. PMH: COPD, HTN, Hx of MRSA. SH: 20 pack year hx. Lung Cancer receiving pembrolizumabm carboplatin, Paclitaxel. After cycle #2, pt developed fever of 102 and ANC 450. Pts MASCC score is 14, CISNE 2 | Cefepime and Vancomycin *look at MASCC score and CISNE score, meet criteria for FN, <21–> inpatient -Hx of MRSA (give them Vancomycin) |
| Correct abx: Pt 56 yo female/ PMH: HTN, Hypothyroidism. Breast cancer treated with tucatinib, trastuzumab, and capecitabine. After cycle #2, pt developed fever of 101F and ANC 499. Pts MASCC: 23 and CISNE 2: -Clindamycin and Augmentin -Cefepime and Vancomycin -Cefepime -Augmentin and Cipro -Meropenem | meets criteria for FN? Yes, triage outpatient. >21, CISNE 2–> only option is Augmentin and Cipro |
Created by:
Xander635
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