Devita, Hellman, and Rosenberg's Cancer

LWBK1006-43 LWW-Govindan-Review December 14, 2011 15:38

546 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

Answer 43.6. The answer is A.

Neutropenic patients with fever require prompt empiric administration of

a broad-spectrum B-lactam antibiotic with activity againstP. aeruginosa,

such as ceftazidime, cefepime, imipenem, or meropenem. The addition of

an aminoglycoside or ciprofloxacin is warranted for patients with hemo-

dynamic compromise. The empiric addition of vancomycin has not been

shown to improve outcomes and is not indicated for initial empiric ther-

apy in hemodynamically stable patients in the absence of clinically appar-

ent catheter-related infections. Vancomycin should also be considered in

patients with severe mucositis, previous use of fluoroquinolone antibiotic

prophylaxis, and history of methicillin-resistantS. aureusinfection.

Answer 43.7. The answer is D.

In patients with persistent neutropenic fever, the addition of antifungal

agents after 4 to 7 days is standard practice. Randomized prospective

studies have shown decreased invasive fungal infections with this strat-

egy. Liposomal amphotericin B, itraconazole, voriconazole, caspofungin,

and micafungin are all acceptable alternatives, with no agent demon-

strating higher overall efficacy than the others. Some authorities feel that

fluconazole or anidulafungin are acceptable alternatives.

Answer 43.8. The answer is D.

Antibiotic treatment of neutropenic fever that resolves after initiation

of empiric therapy should be continued until resolution of neutrope-

nia. For patients with prolonged neutropenia, 2 weeks of antibiotics

may be sufficient. In clinically stable patients, it may be acceptable

to switch initial intravenous antibiotics to an oral regimen, such as

ciprofloxacin with amoxicillin/clavulanate. Some authors have also sug-

gested that select patients can be treated on an outpatient basis with close

monitoring.

Answer 43.9. The answer is C.

Intravascular catheter-associated infections are common given the

widespread use of central venous catheters in patients with cancer. These

consist of exit-site infections, tunnel or pocket infections, and catheter-

related bacteremia. Tunnel (or port) catheter infections typically require

catheter removal. Although catheter salvage may be attempted with cer-

tain pathogens, IDSA guidelines suggest routine removal of catheters for

infections withS. aureus,fungi, and mycobacteria. Attempts at catheter

salvage may be considered withS. epidermidis,with removal of catheter

should bacteremia not be resolved with antibiotics.

Answer 43.10. The answer is B.

Zygomycosis (or mucormycosis) is seen most commonly in patients with

prolonged neutropenia or corticosteroid use, including those with hema-

tologic malignancies and allogeneic HSCT recipients. Sinus or pulmonary

involvement is typical. Therapy should consist of lipid formulation

amphotericin B along with early and aggressive surgical debridement in

those with sinus or localized skin disease. Voriconazole and echinocandins