This document summarizes guidelines for the management of febrile neutropenia. It describes definitions of fever and neutropenia and risk factors. Initial evaluation involves blood cultures, site-specific cultures as indicated, and monitoring. Risk is stratified using tools like the MASCC index. Prophylaxis includes hand hygiene, oral care, and sometimes antibiotics or antifungals. Empiric antibiotic therapy is recommended, with modifications based on risk and response. Therapy typically continues until resolution of fever and recovery of neutrophils. Empiric antifungals may be considered for persistent fever.
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.
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.
“Cancer Anorexia Cachexia (originally Cancer Cachexia) is a multifactorial syndrome defined by:
Ongoing loss of skeletal muscle mass (with or without loss of fat mass)
Cannot be fully reversed by conventional nutritional support
Leads to progressive functional impairment”.
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.
“Cancer Anorexia Cachexia (originally Cancer Cachexia) is a multifactorial syndrome defined by:
Ongoing loss of skeletal muscle mass (with or without loss of fat mass)
Cannot be fully reversed by conventional nutritional support
Leads to progressive functional impairment”.
Top 10 tech support manager interview questions and answersmarcdanny68
In this file, you can ref interview materials for tech support manager such as types of interview questions, tech support manager situational interview, tech support manager behavioral interview…
outh Africa has one of the highest incidences of human immunodeficiency virus (HIV) infection in Africa. The rollout of antiretroviral therapy (ART) in South Africa has been tremendously successful in extending the lives of HIV-infected persons. Consequently, more patients who would have died before the availability of ART are now receiving a diagnosis of HIV-associated nephropathy.1
The rates of disease progression and death in the population of HIV-positive patients with chronic kidney disease can be modified by ART, which reduces the risk of advanced chronic kidney disease among patients with HIV-associated nephropathy by approximately 60%.2,3 It has been estimated that the prevalence of chronic kidney disease among HIV-infected patients receiving treatment is between 8% and 22%4-7; among untreated patients, it is estimated to be between 20% and 27%.8,9 Confronted with a high burden of HIV disease and limited resources, South Africa faces considerable challenges in providing renal-replacement therapy for the large numbers of HIV-infected persons in whom chronic kidney disease will develop during their lifetime.
•Describe the role of antibiotic use in the development of resistance
•Review toxicity of commonly used antibiotics
•Understand the prevalence and clinical impact of carbapenem resistant enterobacteriaceae
•State the prognosis antimicrobial resistant Staph aureus infections
• Describe the role of antibiotic use in the
development of resistance
• Review toxicity of commonly used antibiotics
• Understand the prevalence and clinical impact
of carbapenem resistant enterobacteriaceae
• State the prognosis antimicrobial resistant
Staph aureus infections
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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.
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
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
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
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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2. Febrile Neutropnia
Fever is defined as a single oral temperature of
38.3C (101F) or a temperature of 38.0C
(100.4F) for 1 hour.
Neutropenia is defined as a neutrophil count of
less than 500 cells/mm3, or a count of less than
1000 cells/mm3 with a predicted decrease to
below 500 cells/mm3 in next 48 hours .
4. Impacts of Neutropnia and Febrile
Neutropnia on Survival (cont).
• Epidemiology, management and economic impact of
febrile neutropenia in oncology patients receiving
routine care at a regional UK cancer centre : The
annual incidence of FN was 19.4 per 1000 oncology
admissions. The most common patient groups were those
with breast (27%), lung (16%), ovarian (13%) and oesophageal
(13%) cancers. The mean length of stay was 9.2 days with an
average cost of £2353 for an FN episode per patient. The
attributable mortality rate was 12.5%. The majority (83%) of
patients who died were ≥60 years old.
• S. Schelenz1,*, D. Giles1 and S. Abdallah Oxford Journals Annals of Oncology November 2, 2011
5. What is the Risk ?
•Incidence of Febrile Neutropenia
•Induction-remission for AML : 70-90%
•Elderly patients receiving CHOP : 35-45%
•solid tumors : 10-50%
•Mortality Estimates from Febrile Neutropenia
•Solid tumours : 5%
•Hematological malignancy : Up to 11%
•Gram-positive bacteremia : 5%
•Gram-negative bacteremia : 18%
6. Bacterial pathogens commonly
implicated in neutropenic fever
Substantial fluctuation in the epidemiologic spectrum of bloodstream isolates
obtained from febrile neutropenic patients has occurred over the past 40
years.
Early in the development of cytotoxic chemotherapy, during the 1960s and
1970s, gramnegative pathogens predominated.
Then, during the 1980s and 1990s, gram-positive organisms became more
common because of increased use of indwelling plastic venous catheters, which
can allow for colonization by and entry of gram-positive skin flora
Currently, coagulase-negative staphylococci are the most common blood
isolates in most centers; Enterobacteriaciae (eg, Enterobacter
species, Escherichia coli and Klebsiella species) and nonfermenting gram-
negative rods (eg, Pseudomonas aeruginosa and Stenotrophomonas species)
are isolated less often.
Zinner SH. Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. Clin Infect
Dis 1999; 29:490–4.
7.
8. Initial Evaluation
• Detailed history .
• Comprehensive physical examination (search for potential sites of infection
(skin, nail, oropharynx, gastrointestinal and respiratory tracts, perianal and
genital regions, vascular access and biopsy sites).
• Blood cultures x 2 (for bacterial and fungal organisms), peripheral
blood, and each catheter lumen.
• Sputum microscopy and culture
• Chest radiograph: baseline and with symptoms – CT of the chest
• Urine cultures: symptoms or catheter in place.
• Cerebrospinal fluid, joint fluid: local infection suspected.
• Diarrheal stools: cultures, ova/parasites, C difficile toxin assays .
• Cutaneous lesions: (aspirate / biopsy / wash ) culture.
• CBC, LFTs, RFTs, electrolyte panel: at baseline and every 3-4 days, as
necessary.
• Drainage sites: stain and culture (bacteremia, AFB, fungi, viruses).
9. But be carful
• Symptoms and signs of inflammation may be
minimal or absent in the severely neutropenic
patient, especially if accompanied by anemia
• Diminished or absent induration, erythema, and
pustulation in response to bacterial infection leave
the patient with a cutaneous infection without
typical cellulitis
• Pulmonary infection without discernible infiltrate
on a radiograph,
• meningitis without pleocytosis in the CSF,
• urinary tract infection without pyuria
10. Risk Assessment
• It has become evident that not all febrile
neutropenic patients have the same risk for
developing serious infection and/or complications
during a neutropenic episode
• The purpose of risk assessment is to stratify this
heterogeneous population into meaningful
subgroups based on clinical outcomes, so it may
determine the type of empirical antibiotic therapy
(oral vs intravenous [IV]), venue of treatment
(inpatient vs outpatient), and duration of antibiotic
therapy.
11. • The initial observations made by Bodey and
colleagues indicated that the risk and severity of
infection were greatest in patients with severe
neutropenia ( 100/mm3) that lasted for 2 weeks or more,
what we call now profound neutropnia.
• Most experts consider high-risk patients to be those
with anticipated prolonged (.7 days duration) and
profound neutropenia (absolute neutrophil count [ANC]
<100 cells/ mm3 following cytotoxic chemotherapy)
and/or significant medical co-morbid conditions,
including hypotension, pneumonia, new-onset
abdominal pain, or neurologic changes. Such patients
should be initially admitted to the hospital for empirical
therapy.
Bodey GP, Buckley M, Sathe YS, et al. Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann
Intern Med 1966;64:328-340.[PMID: 5216294
12. MASCC risk-index score [for adults]
the Multinational Association for Supportive Care (MASCC) index allows the clinician to
rapidly assess risk before access to neutrophil count and without knowledge of the burden
of underlying cancer, and has been prospectively validated*.
Scores 21 or more are at low risk of complications.
Criteria Score
Burden of illness(no/mild) 5
Burden of illness(moderate) 3
Burden of illness (sever) 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
* Validation study @ CHOP: Uys et al, Supportive care in Cancer 12(8):555-60, 2004 Aug.
13. Prophylaxis of infection in neutropnic
ptns.
• General measures :
- Handwashing by staff before dealing with ptns
- Skin care of neutropnic ptns ( preventing Staph.
aureues ).
- avoiding of fresh flowers and food with high
bacterial contents
- Teeth should be brushed daily
14. Prophylaxis of infection in neutropnic
ptns.(cont.)
Prophylactic antibiotics :
• Fluoroquinolone prophylaxis should be considered
for high-risk patients with expected durations of
prolonged and profound neutropenia (ANC <100
cells/mm3 for .7 days)
• But we have to know the following
▫ Prophylaxis not associated with reduction in
bacteremia due to Gram positive pathogens or fungi
▫ Quinolone resistance may emerge
▫ Increased MRSA may be seen
▫ Prophylaxis with quinolones associated with Closteridium
difficile diarrhea and colitis
15. Prophylaxis of infection in neutropnic
ptns.(cont.)
• Prophylactic antibiotics (cont) :
Sulfamethoxazole-trimethoprim : Not routine,
except for Pneumocystis prophylaxis ( Leukmia
and AIDS ptns)
16. Prophylaxis of infection in neutropnic
ptns.(cont.)
Antifungal agents :
• Prophylaxis against Candida infection is recommended in
patient groups in whom the risk of invasive candidal infection
is substantial, such as allogeneic hematopoietic stem cell
transplant (HSCT) recipients or those undergoing intensive
remission-induction or salvage-induction chemotherapy for
acute leukemia. Fluconazole, itraconazole, voriconazole,
posaconazole, and caspofungin are all acceptable alternatives.
• Prophylaxis against invasive Aspergillus infections with
posaconazole should be considered for selected patients >13
years of age who are undergoing intensive chemotherapy for
acute myeloid leukemia (AML) or myelodysplastic syndrome
(MDS) in whom the risk of invasive aspergillosis without
prophylaxis is substantial, posaconazole is active in such
setings
17. Antiviral Prophylaxis
• Herpes simplex virus (HSV)–seropositive patients
undergoing allogeneic HSCT or leukemia induction
therapy should receive acyclovir antiviral prophylaxis.
• Antiviral treatment for HSV or varicella-zoster virus
(VZV) infection is only indicated if there is clinical or
laboratory evidence of active viral disease
• Yearly influenza vaccination with inactivated vaccine is
recommended for all patients being treated for cancer.
Optimal timing of vaccination is not established, but
serologic responses may be best between chemotherapy
cycles (.7 days after the last treatment) or .2 weeks
before chemotherapy starts .
18. Guidelines of Management
• Infectious Disease Society of America (IDSA) .
2010 Guidelines for the Use of Antimicrobial
Agents in Neutropenic Patients with Cancer.
19.
20.
21. • Vancomycin not routinely recommended for empiric
therapy
• Use should be limited to specific indications:
▫ clinically suspected serious catheter-related infection
▫ known colonization with MRSA or pcn/ceph-resistant
pneumococci
▫ gram-positive bacteremia pending further C&S
▫ hypotension or other cardiovascular impairment
▫ soft-tissue infection
▫ risk factors for viridans strep bacteremia (severe mucositis)
22.
23. • Other consideration in antibiotics selection :
- Local patterns of infection: Type, frequency,
antibiotic susceptibilities
- Drug allergies
- Drug interactions
- Organ dysfunction (renal and liver)
▫ Cisplatin, amphotericin B, cyclosporine, vancomycin,
and aminoglycosides should be avoided in
combination
▫ Consider need for vitamin K
- Suspected catheter-related infection
- Colonized with MRSA or VRE
24.
25. PERSISTANT FEVER
Evaluate for source of persistent fever
• Noninfectious or nonbacterial etiology
• Resistant pathogen or slow response to therapy
• Emergence of second infection (overgrowth,
superinfection, nosocomial infection)
• Inadequate serum or tissue level of antibiotic(s)
• Drug fever
• Abscess, obstruction, foreign body infection
26.
27. DURATION OF THERAPY
• Afebrile by days 3-5
▫ If ANC >500/mm3 for 2 consecutive days; stop
antibiotics 48 hr after afebrile
▫ If absolute neutrophil count <500/mm3 by day 7
Low risk: stop when clinically well & afebrile
for 5-7 days
High risk (ANC <100/mm3, mucositis,
unstable signs) : continue antibiotics
28. DURATION OF THERAPY (cont)
• Persistent fever
▫ If absolute neutrophil count >500/mm3; stop 4-5
days after ANC > 500/mm3
▫ If absolute neutrophil count <500/m3; continue
for 2 weeks, reassess and stop if no disease sites
29.
30. Role of Empirical or Pre-emptive
Antifungal therapy
• During the first week of febrile neutropenia, evaluations of the
cause of fever focus on bacterial pathogens.
• Candida species are the most common fungal pathogens
during neutropenia, typically occurring during neutropenic
episodes lasting > 1 week, and Aspergillus species are less
common, usually occurring with prolonged neutropenia
lasting > 2–3 weeks
• Past studies* have shown that use of empiric antifungal
therapy in neutropenic patients with persistent fever reduced
mortality compared with patients who did not receive empiric
antifungal therapy
• *Pizzo PA, Robichaud KJ, Gill FA, Witebsky FG. Empiric antibiotic and antifungal therapy for cancer patients with
prolonged fever and granulocytopenia. Am J Med 1982;72:101–111.
31. Empiric antifungal therapy
• Until recently, amphotericin B was the drug of choice for febrile
neutropenia not responding to broad-spectrum antibiotics .
• A small study *comparing itraconazole and AmB demonstrated
higher rates of clinical success (composite of defervescence, absence
of breakthrough fungal infections, and absence of adverse drug
events) with itraconazole.
• Voriconazole , a second-generation triazole with an extended
spectrum that includes molds.
• More recently, caspofungin , of the echinocandin class.
• *Boogaerts M, Winston DJ, Bow EJ, et al. Intravenous and oral itraconazole versus intravenous amphotericin B as empirical antifungal
therapy for persistent fever in neutropenic patients with cancer who are receiving broad-spectrum antibacterial therapy: a
randomized, controlled trial. Ann Intern Med 2001;135:412–422.
32. OTHER THERAPIES
• Antiviral drugs
▫ No indication for empirical use of antiviral agents
▫ Treat HSV or VZV lesions
▫ Consider acyclovir (famiciclovir or valacyclovir)
for suppression of HSV (hematologic malignancy)
▫ In BMT consider need to treat CMV with
ganciclovir or foscarnet
33. OTHER THERAPIES
• Granulocyte transfusions
▫ Not routine
▫ Consider with profound neutropenia and failure to
control bacterial infection despite optimal
antibiotics and G-CSF, and for severe
uncontrollable fungal infections
34. OTHER THERAPIES
• Colony-stimulating factors
▫ Not routine (does not alter infection related-
mortality)
▫ Consider when worsening of course predicted and
expectation of long delay in marrow recovery:
pneumonia, hypotensive episodes, severe cellulitis
or sinusitis, systemic fungal infections, multiorgan
dysfunction secondary to sepsis
▫ Stop when neutrophil count stabilized at >500-
1,000/mm3