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When should a patient receive vancomycin for neurtopenic fever?
- Catheter infection
- G+ w/ no sensitivities yet
- Known colonization of MRSA, PCN/Ceph resistant S. pneumonia
- Soft tissue infection
What antibiotics are used for G + coverage when vancomycin resistance is a problem?
- Linezolid: Caution in BM suppression, CI w/ MAOI
- Daptomycin: monitor weekly, CI pneumonia
- Quinuprisin/Dalfopristin: Musckuloskeletal issues
T/F: If a patient has a continued fever after 3 days of treatment, you should start Vanco empirically.
False, not recommended
If a patient fails initial therapy for Neutropenic fever (still unstable) after 3 days of antibiotics, what should you do?
- Broaden coverage and consider adding CSF if not already on
- Add antifungal treatment?
What antifungals are used in resistant Neutropenic fever?
- Caspofungin – strongest data for use in NF
- Azoles (Only use Posaconazole in high-risk patients with SCT or AML) – Flu is usually initial choice
A low risk patient with NF should receive what initial antimicrobial therapy?
- Oral: Cipro + Augmentin
- IV: Monotherapy: Cefepime or Ceftazidome oor Carbapenem, Dual therapy: Aminoglycoside + antipsuedomonal PCN or any of the previous 3
A high risk patient with NF should receive what initial antimicrobial therapy?
- No vanco needed: Cefepime or Ceftazidome or Carbapenem or Zosyn, Dual therapy: Aminoglycoside + antipsuedomonal PCN or any of the previous 3
- Vanco needed: Vanco + cefepime, ceftazidimes or carbapenem +/- aminoglycoside
When should you intiate Epoetin therapy?
- Hgb <10
- Non-curable disease (metastatic disease)
- Patient agrees to REMS as may increase tumor growth
What is the upper limit for Hgb when using Epoetin?
What are the risks of ESA in cancer?
- Increased Thrombotic events
- Decreased potential survival
- Shorted time to tumor progression
- ESA-neutralizing antibodies
What are the benefits of ESA therapy in cancer?
- Avoid transfusions
- Gradual sustained anemia improvement
What is the REMS program for ESA use in cancer?
When is REMs not required for ESA use in cancer?
Receiving for ESRD and not actively being treated for cancer
What are the ESAs?
- Epoetin alpha
- Darbepotein alpha
How does Darbepotein alpha differ from Epoetin alpha?
Darbepotein alpha is ER
What is the trial period for ESAs?
- Epoetin: 4 weeks increase dose, 8 weeks w/ no response= D/C
- Darbepotein alpha: 6 weeks increase dose, 9 weeks w/no response = D/C
If HgB increases by > 1 gram in 2 weeks w/ ESA use what action should be taken?
Decrease dose by 25% Epoein or 40% for Darbepotein
What is the risk of Hgb increasing more than 1 gram/2 weeks with ESA use?
HTN and Seizures
If Hgb exceeds 11 or 12 g/dL w/ ESA use, what action should be taken?
- Hold doses until Hgb falls below 11 g/dL
- Restart at lower dose
What is the risk associated with Hgb > 11-12 g/dL in a patient using ESAs?
When should supplemental iron be given?
With ESA to achieve transferrin 20-30%, ferritin >100 ng/mL and HgB/Hct 11-12/33-36%
How is supplemental iron administered for anemia in cancer?
IV or PO, recent studies indicate IV should be used
What are the supplemental iron products?
- Iron Dextran
- Ferric Gluconate
- Iron Sucrose
- Ferric carboxymaltose – used when others fail because of expense
Which iron product has the highest risk of reaction?
What are the major SE for iron products?
Anaphylaxis, hypotension and dizziness
What is the mainstay of treatment for Thrombocytopenia?
Transfusion when PLT <10,000 / mm3, S/S of hemorrhage, surgery or infection
What drug stimulates PLT growth and PREVENTS thrombocytopenia?
Oprelvekin (Neumega, IL-11)
What are the SE for Oprelvekin (Neumega, IL-11)?
SOB Edema, Pleural effusion, tachycardia, atrial fibrillation, myalgias/arthalgias
What chemotherapeutic drugs are most likely to cause Mucositis, Esophagitis and Stomatitis?