Neutropenic fever, empiric antibiotics?

[SlaveOfTCMC]

Let's just use a case of post-bone marrow transplant 2 weeks with an indwelling IV catheter


Empiric cefepime is a given

But how about the use of IV vancomycin?

Some studies said there is no empiric benefit of using vancomycin to mortality

Others insist on it because of nosocomial (mainly Staph) infections from the cathether


Does anyone have a good clean rule on this?

Thanks

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[Valadi]

They give cef because it's anti pseudomonal. Gotta get your pseudomonas in neutropenic fever.

Cefepime isn't the only option, though. In general, you should add an anti-pseudomonal to any case of neutropenic fever.

EDIT: Here's a resource with the history as to why they give an anti-pseudomonal: http://jac.oxfordjournals.org/content/63/suppl_1/i14.full.pdf

 

[turkeyjerky]

I think guidelines are to add vancomycin in the case of severe sepsis/hemodynamic instability, pneumonia, and skin or central venous catheter related infections.

Your patient with the in dwelling line doesn't have a CVC, he has a fever.

 

[OveractiveBrain]

Let's just use a case of post-bone marrow transplant 2 weeks with an indwelling IV catheter


Empiric cefepime is a given

But how about the use of IV vancomycin?

Some studies said there is no empiric benefit of using vancomycin to mortality

Others insist on it because of nosocomial (mainly Staph) infections from the cathether


Does anyone have a good clean rule on this?

Thanks

FOR THE TEST: Zosyn = Cefepime (except for neutropenic fever). If not available, Penems (Mero, Erta, etc)

FOR LIFE: The reason you put on Cefepime is pseudomonal coverage. You don't need to treat MRSA empirically right off the bat. Especially if it's only a fever. People DO, but they do it because everyone else uses Vanc and Zosyn, not because they know why. Lets just call Pseudomonas "Gram negative" for righ tnow. You remember why Gram negatives and gram positives are different? Lipopolysaccharides. LPS kills people. It causes massive inflammation and shoots the body into septic shock. Remember, in sepsis its SIRS, not the bug, that causes the damage. The Systemic Immune Response part of systemic immune response syndrome, the body's ability to fight infection, is what leads to devestating consequences. So you don't have two days for cultures to come back. MRSA, on the other hand, regardless of how common it is, can linger in your blood for weeks. In fact, it does (endocarditis, osteomyelitis) but it doesn't kill you. You can wait two days for cultures to come back and tell you "MRSA" or one day for "gram positive cocci in clusters." You DONT have to empirically treat. This is the concept of antibiotic stewardship.

What bug does have LPS? Pseudomonas. What bug doesn't have LPS? MRSA. So why treat empirically for a thing that can just hang around and not do that much damage. What benefit is there to train the regular ole enterococcus to be vancomycin resistant when you aren't getting any mortality benefit?

"Neutropenic patients more vulnerable to pseudomonas. Pseudomonas kills fast because it is gram negative. People who are neutropenic need immediate protection against the thing that kills them fast. Thus, cefepime"

"Neutropenic patients more vulnerable to MRSA. MRSA does not kill fast because it is gram positive. People who are neutropenic do not need immediate protection against the thing that wont kill them fast. Thus, no vanc"

Now, if you don't care about stewardship, and are looking at money, cost, and efficiency, you do both. Why? Because you see TWO DAYS of needed IV antibiotics where you do nothing waiting for cultures to come back. Thats a progress note for two extra days. Thats an ICU or ward bed taken up for two extra days. No insurance company is going to pay for that. At least if you start vanc from the get go, you save TWO DAYS. Who cares about antibiotic resistance. THIS PATIENT, RIGHT NOW is getting out of MY SERVICE! It's not ideal, but it certainly is practical in the system in which we practice. Theoretical correctness (what is tested on step 2) says no need for both vanc and cefepime.

Caveat: HAP/HCAP DOES get vanc and zosyn (cefepime),

 

[SlaveOfTCMC]

thank you very much for a very insightful, knowlegeable, and detailed post.

 

[dienekes88]

FOR THE TEST: Zosyn = Cefepime (except for neutropenic fever). If not available, Penems (Mero, Erta, etc)

FOR LIFE: The reason you put on Cefepime is pseudomonal coverage. You don't need to treat MRSA empirically right off the bat. Especially if it's only a fever. People DO, but they do it because everyone else uses Vanc and Zosyn, not because they know why. Lets just call Pseudomonas "Gram negative" for righ tnow. You remember why Gram negatives and gram positives are different? Lipopolysaccharides. LPS kills people. It causes massive inflammation and shoots the body into septic shock. Remember, in sepsis its SIRS, not the bug, that causes the damage. The Systemic Immune Response part of systemic immune response syndrome, the body's ability to fight infection, is what leads to devestating consequences. So you don't have two days for cultures to come back. MRSA, on the other hand, regardless of how common it is, can linger in your blood for weeks. In fact, it does (endocarditis, osteomyelitis) but it doesn't kill you. You can wait two days for cultures to come back and tell you "MRSA" or one day for "gram positive cocci in clusters." You DONT have to empirically treat. This is the concept of antibiotic stewardship.

What bug does have LPS? Pseudomonas. What bug doesn't have LPS? MRSA. So why treat empirically for a thing that can just hang around and not do that much damage. What benefit is there to train the regular ole enterococcus to be vancomycin resistant when you aren't getting any mortality benefit?

"Neutropenic patients more vulnerable to pseudomonas. Pseudomonas kills fast because it is gram negative. People who are neutropenic need immediate protection against the thing that kills them fast. Thus, cefepime"

"Neutropenic patients more vulnerable to MRSA. MRSA does not kill fast because it is gram positive. People who are neutropenic do not need immediate protection against the thing that wont kill them fast. Thus, no vanc"

Now, if you don't care about stewardship, and are looking at money, cost, and efficiency, you do both. Why? Because you see TWO DAYS of needed IV antibiotics where you do nothing waiting for cultures to come back. Thats a progress note for two extra days. Thats an ICU or ward bed taken up for two extra days. No insurance company is going to pay for that. At least if you start vanc from the get go, you save TWO DAYS. Who cares about antibiotic resistance. THIS PATIENT, RIGHT NOW is getting out of MY SERVICE! It's not ideal, but it certainly is practical in the system in which we practice. Theoretical correctness (what is tested on step 2) says no need for both vanc and cefepime.

Caveat: HAP/HCAP DOES get vanc and zosyn (cefepime),

Interesting. Thanks for the explanation

What about the concept of double coverage for Pseudomonas with combo therapy, e.g. Zosyn/Tobra or Zosyn/Amikacin? Would that be more a function of local resistance patterns?

Also, at what point would you add Micafungin?

 

[medicoQA]

FOR THE TEST: Zosyn = Cefepime (except for neutropenic fever). If not available, Penems (Mero, Erta, etc)

FOR LIFE: The reason you put on Cefepime is pseudomonal coverage. You don't need to treat MRSA empirically right off the bat. Especially if it's only a fever. People DO, but they do it because everyone else uses Vanc and Zosyn, not because they know why. Lets just call Pseudomonas "Gram negative" for righ tnow. You remember why Gram negatives and gram positives are different? Lipopolysaccharides. LPS kills people. It causes massive inflammation and shoots the body into septic shock. Remember, in sepsis its SIRS, not the bug, that causes the damage. The Systemic Immune Response part of systemic immune response syndrome, the body's ability to fight infection, is what leads to devestating consequences. So you don't have two days for cultures to come back. MRSA, on the other hand, regardless of how common it is, can linger in your blood for weeks. In fact, it does (endocarditis, osteomyelitis) but it doesn't kill you. You can wait two days for cultures to come back and tell you "MRSA" or one day for "gram positive cocci in clusters." You DONT have to empirically treat. This is the concept of antibiotic stewardship.

What bug does have LPS? Pseudomonas. What bug doesn't have LPS? MRSA. So why treat empirically for a thing that can just hang around and not do that much damage. What benefit is there to train the regular ole enterococcus to be vancomycin resistant when you aren't getting any mortality benefit?

"Neutropenic patients more vulnerable to pseudomonas. Pseudomonas kills fast because it is gram negative. People who are neutropenic need immediate protection against the thing that kills them fast. Thus, cefepime"

"Neutropenic patients more vulnerable to MRSA. MRSA does not kill fast because it is gram positive. People who are neutropenic do not need immediate protection against the thing that wont kill them fast. Thus, no vanc"

Now, if you don't care about stewardship, and are looking at money, cost, and efficiency, you do both. Why? Because you see TWO DAYS of needed IV antibiotics where you do nothing waiting for cultures to come back. Thats a progress note for two extra days. Thats an ICU or ward bed taken up for two extra days. No insurance company is going to pay for that. At least if you start vanc from the get go, you save TWO DAYS. Who cares about antibiotic resistance. THIS PATIENT, RIGHT NOW is getting out of MY SERVICE! It's not ideal, but it certainly is practical in the system in which we practice. Theoretical correctness (what is tested on step 2) says no need for both vanc and cefepime.

Caveat: HAP/HCAP DOES get vanc and zosyn (cefepime),

Thanks man, there is a qn in CMS, woman has febrile neutropenia post chemo, with chills and central catheter, no s/o catheter infection. She is started on ceftazidime. Qn is what additional antibiotic ? Choices are Imipenem, vanco, and NO additional antibiotics.
Ans is nothing extra needed right ?
Bcos she is already on Anti pseudo .
No signs of catheter infection, so no Vanco
Am i right ?