LWBK1006-43 LWW-Govindan-Review December 14, 2011 15:38
Chapter 43•Infections in the Cancer Patient 545ANSWERS
Answer 43.1. The answer is D.
Patients without a functional spleen are at risk for overwhelming sep-
sis by encapsulated bacteria. The most common causative pathogens
includeS. pneumoniae, H. influenzae,andN. meningitidis. Asplenic
patients should receive the pneumococcal polysaccharide vaccine. The
conjugated meningococcal vaccine is preferred over the polysaccharide
version because it provides longer lasting immunity. Immunization is ide-
ally performed at least 2 weeks before scheduled splenectomy, but may
still be administered after surgery if unable to administer prior to surgery.Answer 43.2. The answer is C.
Antibiotic prophylaxis in neutropenic patients has led to decreased
episodes of fever and decreased infections, but has demonstrated no dif-
ference in mortality in randomized controlled trials. This has primar-
ily been evaluated with oral fluoroquinolones such as levofloxacin. The
benefit is more pronounced in patients with prolonged neutropenia, and
prophylaxis is not routinely recommended in patients expected to have
neutropenia lasting 7 days or less.Answer 43.3. The answer is D.
The most effective prophylaxis is TMP/SMX. Numerous dosing sched-
ules, including one double-strength tablet daily, one single-strength tablet
daily, and one double-strength tablet 3 days per week, appear to be effec-
tive. Second-line agents, including dapsone, inhaled pentamidine, and ato-
vaquone, may be administered in patients unable to receive TMP/SMX
because of marrow intolerance or hypersensitivity reaction, but appear
to be less effective.Answer 43.4. The answer is C.
CMV disease may be prevented in the setting of preexisting infection
through one of two equally acceptable approaches: prophylaxis with
antiviral agents or preemptive therapy. In the latter strategy, active surveil-
lance with highly sensitive methods of detection such as CMV DNA by
PCR may be used to trigger preemptive antiviral therapy in asymptomatic
patients with CMV reactivation. Both strategies are considered appropri-
ate in guidelines published by the Centers for Disease Control and Preven-
tion (CDC), although the preemptive approach is more widely adopted.Answer 43.5. The answer is B.
According to IDSA guidelines, fever is defined as a single oral tempera-
ture of greater than 38.3◦C or a temperature of greater than 38.0◦C for
1 hour or more. Severe neutropenia is defined as a neutrophil count of less
than 500 cells/L or a count of less than 1000 cells/L with a predicted
decrease to less than 500 cells/L.