72F with CML had persistent fever ~102F, cough. CT chest with focal consolidation in LLL. Sputum cx: Klebsiella pneumoniae. Serum BDG, GM negative.
Was on Vanc/Cefepime/LAmB, now narrowed to Cefepime + afebrile 24h
Duration of Cefepime?
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Background:
Up to 50% pts with solid tumors & >80% pts with hem malignancy will develop fever during chemo cycle assoc’d with neutropenia
Only 20-30% of these identify clinical infection
Only 10-25% bacteremia
The very basics:
🔹Here is the classic article from 1966 that demonstrated ⬆️susc to infection as neutrophils<500
🔹Freq and severity of infection inversely proportional to neutrophil count
🔹Risk of severe infection and BSI greatest at ANC <100
pubmed.ncbi.nlm.nih.gov/5216294/
Now setting the definitions straight:
🌡️Fever = Single temp >=38.3C or >=38 sustained over 1 hr period
💠Neutropenia = <500 neutrophils/microL or <1000 with predicted decline to <500 over next 48 hrs
First Q: Can pts ever be treated outpatient with PO abxs for F&N?
Why target with anti-pseudomonal therapy?
🔸Goal of initial empiric therapy = prevent serious M&M fr bact until further cx data available
🔸GN organisms, esp Pseudomonas, associated with high complication and mortality rate
🔸Highlighted below:
pubmed.ncbi.nlm.nih.gov/17689933/
pubmed.ncbi.nlm.nih.gov/2019772/
747 F&N pts randomized to ceftaz+amikacin +/- vanc as initial therapy
🔹No diff by tx regimen in proportion of febrile pts on each day or in fever duration
🔹No pt with GP BSI died during 1st 3d
🔹⬆️nephrotox if tx'd with vanc (6% vs 2%)
2 papers you can look at when thinking about feasibility and safety of short term abx treatment:
How Long study (was included in Cochrane review)
pubmed.ncbi.nlm.nih.gov/29153975/
ANTIBIOSTOP study …nlm-nih-gov.ezp-prod1.hul.harvard.edu/29451055/
IDSA GL: academic.oup.com/cid/article/52…
NCCN GL: NCCN.org
ECIL GL: pubmed.ncbi.nlm.nih.gov/24323983/
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