Patient Encounter 2 Part 2 FN

FG presents to the clinic approximately 8 days after his second cycle of cisplatin-etoposide with a temperature of 38.9°C (102.2°F). He is also hypotensive and cough ing up green sputum. His CBC reveals a WBC of 840 103/|L (840 x 109/L) with 10% (0.10) neutrophils and 15% (0.15) bands. He does not have a central line.

What is FG's ANC?

What treatment goals do you have for FG? Construct an initial treatment plan for this patient.

Pharmacologic Therapy

There are two primary choices for the initial management of high-risk FN: monotherapy and dual therapy (Fig. 99-1). Both regimens have been shown to be equivalent in randomized studies and meta-analyses. Monotherapy avoids the nephrotoxicity of the aminoglycosides and is potentially less expensive, but lacks significant gram-positive coverage and may increase selection of resistant organisms. Dual therapy provides synergistic activity, decreased resistance, and dual coverage of P. aeruginosa, but requires therapeutic monitoring for aminoglycosides.

Vancomycin adds broad-spectrum gram-positive coverage, however the increasing emergence of vancomycin-resistant organisms (i.e., Enterococcus spp) prompts conservative use of this medication. Furthermore, the European Organization for the Research and Treatment of Cancer (EORTC) found that although empiric vancomycin decreased the number of days of fever, it did not improve survival, and also resulted

in increased renal and hepatic toxicities. Thus, vancomycin should only be included as part of the initial therapy in the following cases:

• Severe mucositis

• Soft tissue infection

• Quinolone or TMP-SMX prophylaxis

• Hypotension or septic shock

• Colonization with resistant gram-positive organisms (i.e., MRSA)

• Evidence of central venous catheter infection

Vancomycin may be added to the empiric regimen after 3 to 5 days in persistently febrile patients or if cultures reveal gram-positive organisms. Vancomycin should be changed if the gram-positive organism is susceptible to other antibacterials or discontinued in patients with persistent fever after 3 days with negative cultures. Linezol-id, quiuprostin/dalfoprostin, tigecycline, and daptomycin may be used in cases of vancomycin-resistant organisms or if vancomycin is not an option due to drug allergy or intolerance.

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