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calculation for ANC
WBC (x1000)(cells/mm3) x (% Neutrophils + % Bands)
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risk factors for neutropenic fever
- neutropenia
- immune system disorders
- destruction of protective barriers
- environmental contamination
- alteration of microbial flora
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definition levels for neutropenia
- normal > 1500 cells/mm3
- neutropenia < 500 cells/mm3
- profound neutropenia < 100 cells/mm3
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some disease state that may show an abnormally high WBC but they may be defective
- leukemia
- steroids
- chemotherapy agents
- radiation
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what is nadir
the lowest measurement of the cell line prior to reversal and recovery of the cells, usually 7-10 days
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some disease states that may put a pt at risk of neutropenic fever because of decrease immunity
- lhodgkin's
- transplant
- multiple myeloma
- spenectomy
- CLL (chronic lymphocytic leukemia)
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most common cause of acute bacterial infection among neutropenic pts
- G+ cocci
- S. aureus
- S. epidermidis
- streptococci
- enterococcus
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some G - causative organisms
- E.coli
- K. pneumonia
- P. aeruginsoa
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fungal organisms involved in neutropenia
- candida
- aspergillus
- trichosporon
- fusarium
- curvularia
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parasitic infections
- pneumocystis jiroveci
- toxoplasma gondii
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prophylaxis treatment of parasitic infection
bactrim
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clinical presentation of febrile neutropenia
- single oral temperature of >38.3C (101F) in the absence of other causes
- OR
- >38C for 1 hour or more
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encapsulated organisms
- S. pneumoniae
- H. influenzae
- N. meningitidis
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3 guidelines for empiric therapy of febrile neutropenia
- monotherapy - anti-pseudomonal beta lactam
- 2 drug combo - anti-pseudomonal beta lactam + either and aminoglycoside or an anti-pseudomonal quinolone
- monotherapy or 2 drug combo + vanco
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anti-pseudomonal beta lactams for monotherapy
- cephalosporins: cefepime, ceftazidime
- carbapenem: imipenem-cilastatin, meropenem, doripenem
- penicillin: piperacillin-tazobactam
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what should not be used as monotherapy empiric treatment
- ertapenem & tigecycline low P. aeruginosa coverage
- cipro - poor G+ activity
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4 risk factors to warrant vancomycin as empiric therapy
- clinically apparent catheter related infection
- blood Cx + for G+ bacteria prior to ID and sensitivity
- known colonization w/MRSA or PCN/Ceph resistant pneumococci
- HoTN or septic shock
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organisms caused by contaminated equipment
- P. aeruginosa
- L. pneumophila
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organisms caused by contaminated foods
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2 signs a person has reactivated herpes simplex virus
- gingivostomatitis
- genital lesions
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factors of low risk pts
- neutropenia < 7days
- clinically stable
- few co-morbidities
- no S&S of infection other than fever
- MASCC > 21 pts
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factors of a high risk pt
- neutropenia for > 7days
- profound neutropenia
- clinically unstable
- multiple co-morbidities
- focal infection
- high risk tumor
- MASCC < 21 pt
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if a pt is on vanco empirically when would you discontinue
after 2-3 days no evidence is found of G + infection
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when would we escalate therapy
- persistent fever with deterioration
- add vanco
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when would we consider antifungal therapy
persistent fever after 4-7 days of appropriate abx's and neutropenia is expected to go beyond 7 days
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if we were going to do fungal therapy what would it be
- amphotericin B
- caspofungin
- voriconazole
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when would we consider anti-viral therapy
pts with vesicular lesions or ulcerative skin or mucosal lesions
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if we were going to use anti-viral therapy what would it be
- HSV or VZV
- acyclovir
- valacyclovir
- famiciclovir
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what would we treat citomegallyvirus with
- ganciclovir
- valganciclovir
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what would we use if acyclovir and ganciclovir resistance occurs
foscarnet
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duration of therapy for low risk pts
- ANC < 500
- - blood cultures
- after 5-7 afebrile days
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duration of therapy for profound neutropenia
continue until ANC > 500 and clinically stable
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duration of therapy for persistent neutropenia and febrile but clinically stable, no active infection
2 weeks
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duration of therapy for sinusitis
10-21 days
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duration of therapy for bacterial pneumonia
10-21 days
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duration of therapy for candida
minimum of 2 wks after 1st (-) blood culture
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duration of therapy for apsergillus
min of 12 wks
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duration of therapy for HSV/VZV
7-10 days
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when would we prophylax and with what
- intermediate to high risk, expected profound neutropenic > 7days, HSCT pts
- levofloxacin
low risk cover for viral
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