Neutropenia
Terms
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Clinical Signs of Infection:
Respiratory -
Cough
Purulence (Pus)
Sputum Production
Hyperventilation -
Clinical Signs of Infection:
Urinary -
Pyuria (WBC's)
Frequency -
Clinical Signs of Infection:
Systemic -
Fever / Chills
Hypotension
Hypothermia -
Clinical Signs of Infection:
Neurologic - Mental Status Changes
-
Clinical Signs of Infection:
Skin -
Erythemia (redness)
Pustulation
Lesions - ANC Calculation
- ANC = WBC x [bands/100 + segs/100]
- DEFN: Neutropenic Fever
-
ANC < 500 cells/mm3
Fever 38.3C / 101F
or
> 1hr 38C / 100.4F - Diagnosis and Workup
-
Physical exam
2 blood cultures
Chest Xray
Cultures (urine,stool,skin lesions, sputum) - Pathogens Gram +
-
MRSA = Meth resist. S. Aureus
MSSA = Meth suseptible
S. Epidermidis - Pathogens Gram -
-
E. coli
H. Influenzae
Klebsiella
Pseudomonas
Enterococcus Fecalis - Pathogens Yeast
- Candida Albicans
- Pathogens Fungi
-
Aspergillus
Crypto
Histo - Prevention of Infections:
-
isolaton
Gut decontamination
hand washing
avoid invasive procedures
avoid fruits, vegs, plants, flowers, smoking -
Prevention of Infections:
Anti-microbial prophylaxis -
Cipro 500-750mg po bid
decreases incidence of gram (-) -
Prevention of Infections:
Antifungal Prophylaxis - Fluconazole 400mg po qd in BMT pts
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Prevention of Infections:
Viral Infections -
1) Varicella-Zoster seronegative should avoid others with primary or secondary infxn
2) CMV seronegative to receive seronegative blood -
Treatment:
Penicillin + Aminoglycoside -
Pipercillin 4g q6h
Gentamicin 2mg/kg loading followed by maintenance dose determined by serum conc. -
Treatment:
Antiseudomonal Cephalosporine + Aminoglycoside -
(Cefepime 1-2g q12h
or
Ceftazidime 1-2g q8h)
+
Gentamicin 2mg/kg loading followed by maintenance dose determined by serum conc. -
Treatment:
Aminoglycoside + Quinolone -
Ciprofloxacin 0.4g q 8-12h
+
Gentamicin 2mg/kg loading followed by maintenance dose determined by serum conc. -
Treatment:
Monotherapy -
Cefepime 1-2g q12h
Ceftazidime 1-2g q8h
Piperacillin/tazobactam 4.5g q6h
Imipenem/cilastatin 0.5g q6h
Meropenem 1g q8h - Antifungal Therapy
-
Vorconazole 400mg BID x 2 doses, then 200mg BID
IV: 6mg/kg q12h x 2 doses then 3mg/kg q12h - Vorconazole Concerns
-
Cyclodextran in formulation is toxic with CrCl < 50ml/min
Drug-Drug interactions
Visual Disturbances with IV dosing - Vorconazole Plus's
-
Decreased SE's
Superiority to emperic Amphotericin B -
Amphotericin B therapy:
Esophageal Candidiasis - 0.5 mg/kg/day
-
Amphotericin B therapy:
Disseminated Candidiasis - 0.5 - 1 mg/kg/day
-
Amphotericin B therapy:
Aspergillosis - 1.5 mg/kg/day
-
Amphotericin B therapy:
Lifetime dose - 4 grams (regular product)
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Amphotericin B therapy:
Infusion related / acute effects - Fever, Chills, Nausea, Vomiting
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Amphotericin B therapy:
Chronic Effects - Nephrotoxicity
-
Amphotericin B therapy:
Infusion related / acute effects
TREATMENT -
APAP 650-1000mg po/pr 30min prior
(Avoid NSAIDS b/c increased bleeding effects)
Hydrocortisone for rigors 25-50 mg iv 30 min prior (reasses q3-7 days)
Benadryl ....DOSE??.....
Meperidine 25mg IV q15 min prn rigors up to 100mg over 1 hr caution renal insufficiency -
Amphotericin B therapy:
Nephrotoxicity TREATMENT -
Limit cumulative dose
Hydration and high sodium diet
1L NS qd (NOT Dextrose)
Liposomal formulations with reduced nephrotoxicity -
Amphotericin B therapy:
Electrolyte problems - Mg / K wasting
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Oral Antifungal Agents:
Nystatin for Thrush - 100,000U/ml 5ml swish and swallow QID x 7-10 days
-
Oral Antifungal Agents:
Clotrimazole for Thrush - 10mg Troche 15 - 20 min for slow dissolution 4-5x/day x 7-14 days
-
Oral Antifungal Agents:
Fluconazole for Thrush - 100 mg tab po qd x 7-14 days
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Oral Antifungal Agents:
Fluconazole for Esophogeal Candidiasis - 200 mg qd x 14 - 21 days
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Fever & Neutropenia:
Route of Initial Therapy -
High Risk IV AB's
Low Risk IV or PO -
Fever & Neutropenia:
Initial Therapy Drug Therapy -
If pt. qualifies for vanco, begin 2-3 drug combo with vaco.
(cefepime, ceftrazidime etc. with aminoglycoside) -
Fever & Neutropenia:
Persistent Fever 48-72 hrs - OK wait 5 days to make changes unless clinical deterioration or culture results.
-
Fever & Neutropenia:
Persistent Fever 7 days -
Contiunue Therapy with init. AB's
Change or add AB's
Add antifungal with/without changing antibiotics - Aminoglycoside Benefits
-
Concentration killing
Synergy with other antibiotics