Febrile neutropenia - Infections in cancer patientsAli Musavi
This powerpoint provides a summary of infections in neutropenic patients and febrile neutropenia. It contains the definition, etiology, approach, treatments, and recommendations from ESMO and IDSA guidelines.
I worked on this presentation in 2017, for the Infectious disease department. My sources are: UpToDate, IDSA guidelines. Please share & give me credit to my work.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria.
Febrile neutropenia - Infections in cancer patientsAli Musavi
This powerpoint provides a summary of infections in neutropenic patients and febrile neutropenia. It contains the definition, etiology, approach, treatments, and recommendations from ESMO and IDSA guidelines.
I worked on this presentation in 2017, for the Infectious disease department. My sources are: UpToDate, IDSA guidelines. Please share & give me credit to my work.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria.
The entire scope of febrile neutropaenia in paediatrics subpopulation undergoin cancer chemotherapy including guidelines for risk stratification and mangement.
Sipuleucel_T Immunotherapy for Metastatic Prostate Cancer after Failing Hormo...mjavan2001
This PowerPoint presentation demonstrates findings on a clinical trial of sipuleucel-T in HRPC patients to evaluate overall survival in this group. The FDA approval of Provenge was based on the results of IMPACT study.
Irritable bowel syndrome is a common condition affecting the digestive system.
Symptoms of irritable bowel syndrome include stomach cramps, bloating, diarrhoea and constipation. These may come and go over time.
Making changes to your diet and lifestyle, like avoiding things that trigger your symptoms, can help ease irritable bowel syndrome.
blockage or problem in the urinary tract can mean urine is unable to drain from the kidneys or is able to flow the wrong way up into the kidneys. This can lead to a build-up of urine in the kidneys, causing them to become stretched and swollen.
An injury higher on the spinal cord can cause paralysis in most of your body and affect all limbs (tetraplegia or quadriplegia). A lower injury to the spinal cord may cause paralysis affecting your legs and lower body (paraplegia)
Scoliosis is the abnormal twisting and curvature of the spine. It is usually first noticed by a change in appearance of the back. Typical signs include: a visibly curved spine. one shoulder being higher than the other.
Osteoarthritis (OA) is the most common form of arthritis. Some people call it degenerative joint disease or “wear and tear” arthritis. It occurs most frequently in the hands, hips, and knees.
With OA, the cartilage within a joint begins to break down and the underlying bone begins to change. These changes usually develop slowly and get worse over time. OA can cause pain, stiffness, and swelling. In some cases it also causes reduced function and disability; some people are no longer able to do daily tasks or work.
About 4 out of 5 cases of acute pancreatitis improve quickly and don't cause any serious further problems. However, 1 in 5 cases are severe and can result in life-threatening complications, such as multiple organ failure. In severe cases where complications develop, there's a high risk of the condition being fatal.
Guillain Barre Syndrome (GBS) is a serious disorder that occurs when the body’s defense (immune) system mistakenly attacks part of the nervous system i.e Autoimmune Disorder.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. Febrile Neutropenia
Considered primary cause of
mortality in 36% of cancer patients
Considered secondary cause of
mortality in 68% of cancer patients
It is the most common cause of
mortality and morbidity
@mukeshdelano 3
4. Incidence of Febrile
Neutropenia
Incidence of Febrile Neutropenia
Induction-remission for AML 70-90%
Elderly patients receiving
CHOP
35-45%
Mortality Estimates from Febrile Neutropenia
Hematological malignancies 11%
Gram-positive bacteremia 5%
Gram-negative bacteremia 18%
@mukeshdelano 4
6. Neutropenia
Decrease in the absolute number of circulating segmented neutrophils and band
cells in peripheral blood
Absolute Neutrophil count (ANC) = Total white blood cells/micro L * Percent
(PMNs + Band cells) /100
At birth – predominant but rapid decrease begins at 12 hour through the 1st
week of life
Infancy – 20-30% of TLC
At 5 years – equal number of neutrophils and lymphocyte count
In Adults – characteristic 70% predominance of neutrophils is usually attained
during puberty
@mukeshdelano 6
7. Pathophysiology
Neutropenia is most commonly seen as a result of cytotoxic therapy although
the ANC of individuals can drop significantly through cancer’s direct interaction
with hematopoiesis (e.g. in leukemia) or the bone marrow metastatic
replacement
When neutropenia is associated with an increase in the body temperature, the
patient has usually developed a pathological infection which is caused in 33% of
the cases by pathogenic microorganisms
Exogenous pyrogens induce several cytokines which activate immune
responses, and produce fever.
@mukeshdelano 7
8. Types
Neutropenia Absolute Neutrohil count
Normal 1500 -8000 /cu mm
Neutropenia < 1500 /cu mm
Mild 1000-1500 /cu mm
Moderate 500-1000/ cu mm
Severe < 500/ cu mm
Profound < 100/cu mm
Prolonged Neutropenia – Lasting more than 7 days
Chronic Neutropenia –last more than 3 months
Functional Neutropenia: Impaired function of circulating neutrophils as seen in certain hematologic malignancies
Constitutional neutropenia is neutropenia of longstanding duration, typically since childhood
@mukeshdelano 8
9. What's febrile neutropenia?
• Fever: Single oral temperature ≥38.3°C or
persistent temperature ≥38.0 °C (100.4 F) for >1
hour OR Two consecutive temperature >38.3 °C in
a 12 hr period for at least 1 hr
• Neutropenia: ANC <0.5, or ANC <1.0 and a
predicted decline to <0.5 over next 48 hrs.
(ANC= absolute neutrophil count)
@mukeshdelano 9
12. History & physical examination
Differential CBC , RFT , LFT , Electrolytes & uric acid
At least 2 sets of blood cultures & culture specimens from sites
of suspected infection
Sputum culture
Urine analysis
CXR is indicated for patients with respiratory signs or symptoms
@mukeshdelano 12
13. Detailed H & P
History
Fever – onset, duration, severity
Chemotherapy regimen & last dose given
Vascular devices
Prophylactic antibiotic
Steroid use
Major comorbid illnesses
Recent hospitalization and antibiotics received
@mukeshdelano 13
14. Site specific H & P
Examinations
Eyes Conjunctivitis, Orbital cellulitis
Ear, Nose and Throat Otitis media, sinusitis, Tonsillitis,
Pharyngitis, Oral candidiasis
Teeth Dental caries/abscess
Respiratory system Pneumonia
Abdomen Diarrhea, Dysentery, Neutropenic
enterocolitis, Pseudomembranous
colitis
Perineum Perianal candidiasis, Perianal abscess
Skin Cellulitis, Abscess, Nodular or target
lesions, Varicells rashes
genitourinary Yeast Infections, UTIs
CNS Meningitis, Meningo encephalitis,
Cavernous sinus Thrombosis
@mukeshdelano 14
16. Risk status Assessment
Low Risk High Risk
Outpatient at time of fever Inpatient at time of fever
No acute comorbid illnesses Significant medical comorbidity
Anticipated short duration of severe
neutropenia (<7 days)
Anticipated severe or prolonged
neutropenia (>7 days)
(absolute Neutrophil count [ANC] <100
cells/mm3)
No renal insufficiency CrCL <30 ml/min
No hepatic insufficiency Transaminases ≥5x ULN
Good performance status Uncontrolled/progressive cancer,
Mucositis grade 3-4
MASCC Risk Index score ≥21 MASCC Risk Index score <21
Complex infection
@mukeshdelano 16
17. What is MASCC
(The Multinational association for supportive care in
cancer Patient )
Prospectively validated tool to rapidly assess risk before access to neutrophil count.
criteria score
Burden of illness (No/Mild) 5
Burden of Illness (Moderate) 3
Burden of Illness (severe) 0
No Hypotension 5
No COPD 4
Solid tumor/Lymphoma
No previous fungal infection
4
No Dehydration 3
Outpatient status (onset of fever) 3
Age <60 years 2
Characteristic/Score
@mukeshdelano 17
18. Type of Cancer
Solid tumor 4
Lymphoma with previous fungal infection 4
Hematologic with previous fungal infection 4
No dehydration 4
Outpatient status (at the onset of fever) 3
Age less than 60 years 2
@mukeshdelano 18
19. The Clinical Index of Stable
Febrile Neutropenia Score
ECOG performance status (greater than 2) 2
Chronic obstructive pulmonary disease (COPD) 1
Stree-induced hyperglycemia 2
Chronic cardiovascular disease 1
Monocytes less than 200 per mcL 1
Grade greater than or equal to 2 mucositis 1
Interpretation
Characteristics/Score
0-2/Consider
outpatient
management with oral
antibiotics
Greater than or equal
to 3/inpatient
management
CISNE/Recommendation
@mukeshdelano 19
20. Low Risk Treatment
Low risk, adult patients
No focus of infection, hemodynamically stable
No systemic symptoms other than fever
No organ failure, pneumonia, soft tissue infection
Recovering bone marrow
Reliable patient
Hospital admission is required for persistent fever or signs and
symptoms of infection.
Vigilant observation
Access to medical care 24-7
Return to clinic if
1. Positive cultures
2. Persistent/recurrent fever (3-5 days)
3. Unable to tolerate PO regimen
Cipro 500 mg PO Q8h + amoxicillin-
clavulanate 500 mg PO Q8h
@mukeshdelano 20
25. IV combination Therapy
Advantages Disadvantages:
Synergistic effect against gram-neg Lack of activity against gram-pos?
Reduced emergence of resistance Toxicity
Intravenous PIPERACILLIN-TAZOBACTAM, OR
Intravenous IMIPENEM OR MEROPENEM, OR
Intravenous CEFEPIME OR CEFTAZIDIME
Aminoglycoside + (Any of above)
Ciprofloxacin + (Any of above)
First Line of defense
@mukeshdelano 25
26. Second line
Intravenous PIPERACILLIN-TAZOBACTAM, OR
Intravenous IMIPENEM OR MEROPENEM, OR
Intravenous CEFEPIME OR CEFTAZIDIME
+
Vancomycin
Third line
Colistin is reserved as third drug
If anaphylaxis allergy to beta-lactams, treat with
VANCOMYCIN + AMINOGLYCOSIDE + CIPROFLOXACIN
@mukeshdelano 26
27. IV Therapy Options:
Comparison
Piperacillin-tazobactam
Broad spectrum gram(-), gram(+) & anaerobic coverage
Use for intra-abdominal source
Not recommended for meningitis (poor CSF penetration)
Meropenem
Broad spectrum gram(-), gram(+) & anaerobic and ESBL
coverage
Use for intra-abdominal source
Preferred for meningitis/CNS infection
@mukeshdelano 27
28. IV Therapy Options:
Comparison
Imipenem-cilastin
Broad spectrum gram(-), gram(+) & anaerobic and ESBL
coverage
Risk of seizures in CNS malignancy or renal impairment
Ceftazidime
Poor gram(+) activity
Breakthrough streptococcal infections
No activity against anaerobes, enterococcus
Good CSF penetration
@mukeshdelano 28
29. IV Treatment Options:
Comparison
Aminoglycosides
Gram(-) coverage, synergy with beta-lactams against S.aureus and
Enterococcus
Nephrotoxicity, ototoxicity
Ciprofloxacin
Gram(-) and atypical bacterial coverage
No anaerobic coverage, less gram(+) activity than other options
Good clinical studies as empirical PO or IV therapy
Avoid in patients recently treated with quinolone prophylaxis
Levofloxacin: better gram (+) coverage but limited studies
available for use as empiric therapy.
@mukeshdelano 29
30. Vancomycin
Is not recommended as a standard part of the initial
antibiotic regimen for fever and Neutropenia
Clinical indications:
Catheter-related infection
Skin or soft-tissue infection
Pneumonia confirmed
Hemodynamic instability - Hypotension
Severe Mucositis
@mukeshdelano 30
32. If an infection is documented, for
how long ABs should be continue?
Resolution of signs and symptoms of infection
Always treat 10-14 days for
Bloodstream infection
Soft tissue infection
Pneumonia
@mukeshdelano 32
33. If infection is undocumented, for
how long ABs should be continue?
Patient can be changed from IV to PO treatment if
a febrile after 3 days of therapy and clinically stable
Use fluoroquinolone (Levofloxacin ) for remainder
of neutropenia
@mukeshdelano 33
34. If no improvement?
Empericial antifungal coverage should be considered in patients
who have persistent fever after 4-7 days of broad-spectrum
antibacterial regimen and no identified fever source
Oral thrush, Mucositis : Mouthwash, Fluconazole
Esophageal lesions: Fluconazole
Sinus/nasal symptoms and suspicious CT/MRI: Amphotericin B
Pneumonia: voriconazole, amphotericin B
Empiric treatment required based on H&P as positive cultures
can take several days.
@mukeshdelano 34
35. Antifungals Added Later?
IDSA recommends consider antifungal if febrile
after 3-5 days and remains neutropenic
Amphotericin B is preferred
Fluconazole may be acceptable at institutions with
low rates of mold infections or drug-resistant
Candida species
@mukeshdelano 35
36. Antifungals Added Later?
NCCN recommends:
Add fluconazole if
• no prior azole antifungal prophylaxis,
• low risk for invasive aspergillosis and
• low rates of azole-resistant Candida.
Dosing:
• 150 mg PO x1 dose for vaginal candidiasis
• 200 mg PO daily x14 days for candidal pyelonephritis
• 800 mg x1 then 400 mg daily x14 days from first negative culture for
candidiasis (not recommended if received prophylaxis)
• 400 mg PO daily prophylaxis for neutropenic patients
@mukeshdelano 36
37. NCCN Recommends
Add voriconazole, liposomal amphotericin B or an echinocandin if
already exposed to an azole or known to be colonized with non-
albicans Candida.
Voriconazole 6 mg/kg IV q12h x2 doses then 4 mg/kg IV/PO q12h
Amphotericin B 3-5 mg/kg IV daily
Caspofungin 70 mg IV x1 then 50 mg IV daily; 70 mg IV daily for
aspergillosis
Continue until neutropenia has resolved, or for at least 14 days in
patients with a demonstrated fungal infection.
@mukeshdelano 37
39. Antiviral Doses
Acyclovir
Mucocutaneous HSV: 5 mg/kg IV Q8h
Single dermatomal VZV: 800 mg PO 5x/day or 5 mg/kg IV Q8h
Disseminated VZV or HSV: 10 mg/kg IV Q8h
Valacyclovir
HSV or VZV treatment: 1g PO Q8h
Ganciclovir:
CMV treatment: 5 mg/kg IV Q12h x2 weeks then 5 mg/kg IV Q24h x2-4 weeks
Acyclovir-resistant HSV: 40 mg/kg IV Q8h
CMV treatment: 90 mg/kg IV Q12h x2 weeks then 120 mg/kg IV Q24h x2-4 weeks
Oseltamivir:
Influenza: 75 mg PO Q12h
(reduced doses required in renal impairment)
@mukeshdelano 39
40. Assessment of Response
Daily assessment until afebrile and ANC >0.5
Fever
CBC
Renal function
Clinical Symptoms
@mukeshdelano 40
41. Duration of Therapy
Afebrile and ANC >= 0.5 x48 hrs:
Low risk patients, no source of infection identified: can discontinue abx
High risk patients or with documented infection: continue tailored therapy
>=7 days
Afebrile but ANC <0.5 after 5-7 days:
low risk: can discontinue abx
high risk: continue abx until ANC >0.5 or 14 days in pts not expecting ANC
recovery.
IDSA 2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer
@mukeshdelano 41
42. Febrile:
Neutropenic: continue abx at least 14 days, reassess
for non-response
Non-neutropenic: discontinue abx 4-5 days after ANC
>0.5 if no source of infection identified
IDSA 2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer
@mukeshdelano 42
43. Follow up for Non-
Responsive Patients
Febrile but otherwise stable
If non-neutropenic consider stop abx 4-5 days after ANC
>0.5
Consider antifungal therapy with activity against mold if
fever continuing ≥4-5 days.
Febrile and clinically unstable
Broaden coverage to include anaerobes, resistant gram
negative, resistant gram positive organisms
Ensure coverage of Candida
Consider antifungal therapy with activity against mold if
fever continuing ≥4 days of therapy
@mukeshdelano 43
44. Duration of Therapy for
Documented Infection
Aspergillus min 6-12 weeks
Viral:
HSV/VZV: 7-10 days
Influenza: ≥5 days
@mukeshdelano 44
47. Indication of prophylaxis
Allogeneic hematopoietic stem cell transplant recipients.
Those undergoing intensive induction or salvage-induction
chemotherapy for leukemia
prolonged and profound neutropenia (ANC <100 cells/mm3
for >7 days)
@mukeshdelano 47
48. Drugs can be used
Abs Fluoroquinolone (Levofloxacin)
Antifungal Fluconazole, itraconazole, voriconazole and caspofungin are all acceptable
alternatives
Antiviral Acyclovir Herpes seropositive recieving agressives chemotherapy.
@mukeshdelano 48
49. What Is the Role of Growth Factors in
Management?
CSFs are not generally
recommended for
treatment of established
fever and neutropenia
CSF should be
considered as
Prophylactic only
@mukeshdelano 49
50. What environmental precautions
should be taken when managing FN?
Hand hygiene is the most effective means of preventing transmission of
infection in the hospital
Patients should be placed in private (ie, single patient) rooms with air
exchanges and particulate air filtration.
Plants and dried or fresh flowers should not be allowed
Encourage health care workers to report their illnesses or exposures.
@mukeshdelano 50
51. Hematopoietic growth factor for
Preventing Febrile Neutropenia
Administering more than 600 µg/day of granulocyte-
colony stimulating factor (G-CSF) prevents recurrence
of febrile neutropenia during chemotherapy
Higher dosing does not increase side effects
@mukeshdelano 51
52. Pegfilgrastim (Rx)
G-CSF (Filgastim) @ 2-5mcg/kg/day in addition to antibiotics
is useful with complicated febrile Neutropenia (Pneumonia,
Hypotension, Invasive fungal investion or MODS)
6mg SC once per chemotherapy cycle
@mukeshdelano 52
53. Advantages
More rapid Neutrophil recovery
shortens days of antibiotics use
Shortens length of hospital stay
Reduces mortality and morbidity
But G-CSF has no role in the management of children with uncomplicated neutropenia
@mukeshdelano 53