Podcast
Questions and Answers
What defines neutropenia in terms of absolute neutrophil count (ANC)?
What defines neutropenia in terms of absolute neutrophil count (ANC)?
Which criterion characterizes a patient as high-risk for neutropenic fever?
Which criterion characterizes a patient as high-risk for neutropenic fever?
For low-risk neutropenic patients, what is a suitable oral empiric therapy regimen?
For low-risk neutropenic patients, what is a suitable oral empiric therapy regimen?
What is indicated for high-risk neutropenic fever patients regarding their management?
What is indicated for high-risk neutropenic fever patients regarding their management?
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Which of the following describes a low-risk patient with neutropenic fever?
Which of the following describes a low-risk patient with neutropenic fever?
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What is a main factor that influences the choice of empiric therapy for neutropenic patients?
What is a main factor that influences the choice of empiric therapy for neutropenic patients?
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In the MASCC scoring system, what is the purpose?
In the MASCC scoring system, what is the purpose?
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What monitoring is required for low-risk neutropenic patients receiving outpatient therapy?
What monitoring is required for low-risk neutropenic patients receiving outpatient therapy?
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Which of the following antibiotics is NOT acceptable as monotherapy for febrile neutropenia?
Which of the following antibiotics is NOT acceptable as monotherapy for febrile neutropenia?
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In high-risk patients with complicated cases of febrile neutropenia, which antibiotic combination is appropriate?
In high-risk patients with complicated cases of febrile neutropenia, which antibiotic combination is appropriate?
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What is the recommended addition of vancomycin indicated for?
What is the recommended addition of vancomycin indicated for?
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When should therapy be adjusted if an organism is identified?
When should therapy be adjusted if an organism is identified?
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If fever persists after 3-5 days and the ANC is greater than 500/μL, what should be done?
If fever persists after 3-5 days and the ANC is greater than 500/μL, what should be done?
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Which anticoagulant agent should be used if the patient is at risk of infection with antibiotic-resistant organisms such as MRSA?
Which anticoagulant agent should be used if the patient is at risk of infection with antibiotic-resistant organisms such as MRSA?
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What should be done if a patient remains febrile after 4-7 days of broad-spectrum antibiotics but is clinically stable?
What should be done if a patient remains febrile after 4-7 days of broad-spectrum antibiotics but is clinically stable?
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What is the typical duration for which antibiotics should be continued for a patient with neutropenia if no organism is identified and ANC is less than 500/μL?
What is the typical duration for which antibiotics should be continued for a patient with neutropenia if no organism is identified and ANC is less than 500/μL?
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Which antifungal agent is NOT listed among those recommended for empiric therapy in febrile patients?
Which antifungal agent is NOT listed among those recommended for empiric therapy in febrile patients?
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Which of the following best describes the use of colony-stimulating factors in chemotherapy?
Which of the following best describes the use of colony-stimulating factors in chemotherapy?
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What is the purpose of adjusting antibiotic therapy based on an identified organism?
What is the purpose of adjusting antibiotic therapy based on an identified organism?
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If a patient is clinically stable and has a low risk of fungal infection, what is the recommended approach to antifungal therapy?
If a patient is clinically stable and has a low risk of fungal infection, what is the recommended approach to antifungal therapy?
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What is the recommended dosing for Piperacillin-tazobactam when used in monotherapy?
What is the recommended dosing for Piperacillin-tazobactam when used in monotherapy?
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Which of the following should be monitored if antibiotic therapy is continued beyond 7 days?
Which of the following should be monitored if antibiotic therapy is continued beyond 7 days?
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Study Notes
Neutropenic Fever Empiric Therapy
- Neutropenia Definition: Absolute neutrophil count (ANC) less than 500/μL, or less than 1000/μL with anticipated decline to less than 500/μL in 48 hours.
- Neutropenic Fever Definition: Single oral temperature of 38.3°C (101°F) or sustained temperature above 38.0°C (100.4°F) for over an hour in a neutropenic patient.
- Patient Risk Assessment: Crucial for determining appropriate therapy (oral vs. IV), duration, and inpatient/outpatient management. High-risk vs. low-risk classification.
- High-Risk Patients: Characteristics include; anticipated, prolonged (>7 days), profound neutropenia (ANC < 100/μL) following cytotoxic chemo; significant medical comorbidities (hypotension, pneumonia, new-onset abdominal pain, neurologic changes).
- Low-Risk Patients: Characteristics include; anticipated brief (<7 days) neutropenia; ANC > 100/μL and absolute monocyte count > 100/μL; normal chest X-ray; outpatient status at fever onset; no acute comorbidity; no hepatic/renal insufficiency; early bone marrow recovery.
Low-Risk Patient Regimens
- Oral Empiric Therapy: Amoxicillin-clavulanate (500 mg/125 mg PO q8h) + ciprofloxacin (500 mg PO q12h).
- Alternative: Moxifloxacin (400 mg PO daily).
- Penicillin Allergy Substitution: Clindamycin (300 mg PO q6h) for amoxicillin-clavulanate.
- Outpatient Monitoring: Daily office visits for at least 72 hours.
High-Risk Patient Regimens (Hospitalized)
- First-Line Monotherapy (anti-pseudomonal required): Piperacillin-tazobactam (4.5 g IV q6h), Cefepime (2 g IV q8h), Meropenem (1 g IV q8h), Imipenem-cilastatin (500 mg IV q6h) are suitable.
- Second-Line Dual Therapy (complications/resistance): Piperacillin-tazobactam + aminoglycoside; Cefepime + aminoglycoside; Meropenem + aminoglycoside; Imipenem-cilastatin + aminoglycoside.
- Aminoglycoside Options: Gentamicin (2 mg/kg IV q8h or 5 mg/kg q24h), Amikacin (15 mg/kg/day), Tobramycin (2 mg/kg q8h).
Vancomycin Considerations
- Indications: Clinically suspected serious catheter-related infections, known colonization with penicillin/cephalosporin-resistant pneumococci or methicillin-resistant Staphylococcus aureus (MRSA), blood culture positive for gram-positive bacteria, hypotension, severe mucositis (if prior fluoroquinolone prophylaxis).
Additional Considerations for Antibiotic-Resistant Organisms
- MRSA: Vancomycin, linezolid, or daptomycin.
- Vancomycin-resistant enterococcus (VRE): Linezolid or daptomycin.
- ESBL-producing gram-negative bacteria: Carbapenem (e.g., meropenem).
- Carbapenemase-producing organisms: Polymyxin-colistin or tigecycline.
Fever Resolution (3-5 days or More)
- Identified Organism: Adjust antibiotics based on organism & infection site; 7+ days of therapy until negative cultures and clinical improvement.
- No Organism Identified, ANC > 500/μL for 2 Consecutive Days: Change to amoxicillin-clavulanate + ciprofloxacin; discontinue after 5-7 days of afebrile period.
- No Organism Identified, ANC < 500/μL: Continue current regimen until day 7; low-risk/stable at day 7, discontinue antibiotics; high-risk, continue for 2 weeks or until neutropenia resolves.
- Fever Persists > 3-5 Days (ANC > 500/μL): Continue current regimen, stop after ANC > 500/μL. Assess for undiagnosed fungal infection.
- Fever Persists > 3-5 Days (ANC < 500/μL): Add vancomycin (if not already on) per criteria. Consider discontinuing vancomycin if MRSA cultures are negative. Add empiric antifungal therapy if needed.
Antifungal Agents (Empiric)
- Options: Amphotericin B liposomal, voriconazole, posaconazole, itraconazole IV/PO, caspofungin, micafungin, anidulafungin.
- Considerations: Withhold in specific high-risk stable patients without fungal signs after 4-7 days of broad-spectrum antibiotics. Avoid routine use in low-risk patients.
- Duration: 2 weeks if stable and no infectious nidus is found, switching classes if fever persists is needed.
Special Considerations
- Colony-stimulating factors (CSFs): Prophylactic use can reduce neutropenic fever incidence; consider when risk is high. Chemotherapy dose reduction is considered for palliative chemo intent. Use of CSFs for established fever and neutropenia is not generally recommended.
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Description
This quiz covers the definitions of neutropenia and neutropenic fever, along with the critical aspects of patient risk assessment for empiric therapy. Participants will learn to differentiate between high-risk and low-risk patients based on specific characteristics. Enhance your understanding of patient management in neutropenia contexts.
