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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
- Unstable
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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
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T/F: If a patient has a continued fever after 3 days of treatment, you should start Vanco empirically.
False, not recommended
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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?
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What antifungals are used in resistant Neutropenic fever?
- Caspofungin – strongest data for use in NF
- Micafungin
- Anidulafungin
- Azoles (Only use Posaconazole in high-risk patients with SCT or AML) – Flu is usually initial choice
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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
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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
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When should you intiate Epoetin therapy?
- Hgb <10
- Non-curable disease (metastatic disease)
- Patient agrees to REMS as may increase tumor growth
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What is the upper limit for Hgb when using Epoetin?
11-12
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What are the risks of ESA in cancer?
- Increased Thrombotic events
- Decreased potential survival
- Shorted time to tumor progression
- ESA-neutralizing antibodies
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What are the benefits of ESA therapy in cancer?
- Avoid transfusions
- Gradual sustained anemia improvement
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What is the REMS program for ESA use in cancer?
APPRISE
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When is REMs not required for ESA use in cancer?
Receiving for ESRD and not actively being treated for cancer
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What are the ESAs?
- Epoetin alpha
- Darbepotein alpha
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How does Darbepotein alpha differ from Epoetin alpha?
Darbepotein alpha is ER
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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
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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
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What is the risk of Hgb increasing more than 1 gram/2 weeks with ESA use?
HTN and Seizures
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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
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What is the risk associated with Hgb > 11-12 g/dL in a patient using ESAs?
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When should supplemental iron be given?
With ESA to achieve transferrin 20-30%, ferritin >100 ng/mL and HgB/Hct 11-12/33-36%
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How is supplemental iron administered for anemia in cancer?
IV or PO, recent studies indicate IV should be used
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What are the supplemental iron products?
- Iron Dextran
- Ferric Gluconate
- Iron Sucrose
- Ferric carboxymaltose – used when others fail because of expense
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Which iron product has the highest risk of reaction?
Dextran
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What are the major SE for iron products?
Anaphylaxis, hypotension and dizziness
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What is the mainstay of treatment for Thrombocytopenia?
Transfusion when PLT <10,000 / mm3, S/S of hemorrhage, surgery or infection
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What drug stimulates PLT growth and PREVENTS thrombocytopenia?
Oprelvekin (Neumega, IL-11)
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What are the SE for Oprelvekin (Neumega, IL-11)?
SOB Edema, Pleural effusion, tachycardia, atrial fibrillation, myalgias/arthalgias
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What chemotherapeutic drugs are most likely to cause Mucositis, Esophagitis and Stomatitis?
- Methotrexate
- 5-FU
- Doxorubicin
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