Dr. Strong, You are amazing, I used to be worried you would sell out one day! I hope you never feel that you have to! I get happy every time I see you are still contributing to the world "just because". Your name will be remembered in history as one of the greatest educators! You are my role model!
To the point lectures- really gain a lot of clinical knowledge from these lectures and experiences Would love if you could update the antibiotic lectures from 9-10 years ago. Recently, also viewing the ID podcasts from Mofett. AGAIN THANK YOU!
Thanks for the suggestions for videos on CKD. I haven't directly covered it as of yet because it's a little more outside the scope of my practice than most of the topics here, and will require a bit more reading on my part before feeling like I have something to add to the resources that are already out there. But it is on my list of topics I'd like to cover.
@@StrongMed Yes, also it is a very intricate and arid subject. I mean, it is very fun to study because a very rich pathophysiology and management, but it is a lot.
Couple of questions 1) Is there any way to predict the duration of neutropenia with somewhat reliable accuracy? 2) Is there any particular bacteria we're concerned about in severe cases, so much so that we're empirically adding FQ or aminoglycosides? Aren't vancomycin and Zosyn broad enough?
1. There are some general trends seen with specific chemotherapy regimens. For example, neutropenia is most severe and most prolonged in patients undergoing the pre-engraftment phase of hematopoietic cell transplantation, or those undergoing induction chemotherapy for acute leukemia. There are more specific rules-of-thumb about anticipated duration from specific chemo regimens - unfortunately I can't find a good reference to direct you to at the moment. Also, *in general* the risk factors for prolonged neutropenia, severe neutropenia, and neutropenic fever have much overlap. 2. The reasons for adding either a FQ or AG to the anti-pseudomonal beta-lactam is usually given as a combination of the possibility of Pseudomonas resistance to the beta lactam, and in vitro studies showing more rapid bacterial killing with combination therapy as compared to beta-lactam monotherapy (though with the tradeoff of more drug toxicity when used in actual people!) As I mentioned in the video, where I practice I have never personally seen a beta-lactam + empiric AG used for neutropenic fever. When double coverage of Pseudomonas is thought to be important, I've always seen beta-lactam + either cipro or levo used. However, antibiotic resistance patterns change over time and are not consistent across geography, so if local ID docs recommend something different where you practice, I would go with them.
Do you start empiric antibiotics before you receive the neutrophile count to see if the patient is actually neuotropenic, or should you start it right after cultures are drawn if the patient has fever?
It would depend on the situation - specifically, what is the probability the patient is neutropenic, and how long will it take for the neutrophil count to be reported by the lab. I'd say in almost cases, for a patient undergoing chemotherapy who comes in to the ER for a fever (or other infectious symptoms), if the timing of the fever is concurrent with when neutropenia might be expected, I'd start antibiotics as soon as cultures are drawn (i.e. not waiting for the neutrophil count). In other words, I'd only wait for the neutrophil count if the pretest probability for neutropenia was low - unless the neutrophil count was going to take many hours to be reported. In general, the benefit of giving antibiotics quickly in a patient with neutropenic fever is much greater than the harm of giving a single dose of antibiotics to a patient who doesn't need it.
Oof that solid tumor or no previous fungal infection for 4 points is an interesting and rough one. I’m guessing that’s because of fungal infections tendency to pop up later and the continuous nature of liquid tumor chemotherapy
Hi Dr Strong, another great video as usual! After doing my Haematology/Oncology job I now routinely ask patients about perianal pain/rectal pain due to being caught out by patients with prolonged neutropenic sepsis due to what seemed like a forgettable symptom, but on MRI demonstrated neutropenic proctitis and anal fistula. Are perianal and rectal sources of neutropenic infection something you’ve unexpectedly encounted as well? Also, with regards to aminoglycosides it’s very common in the UK to use Gentamicin as the sepsis “panic button” for double coverage of gram -ve organisms. E.g “if deteriorates give STAT dose of 5mg/kg gent”
Thanks for mentioning these points! Regarding, perianal/rectal sources for neutropenic fever, I have also heard this from others but have not personally seen it myself - though if you specifically work on a heme/onc service, you probably have a much greater sample size on this than I do being on a gen med service. With AGs, in the US physicians seem particularly apprehensive about the associated renal toxicity - leading to a discordance between expert recommendations and common practice (with both neutropenic fever, and in other circumstances as well).
@@StrongMed The renal toxicity is definitely a thing geriatricians and nephrologists love to complain about over here! Common lines like “the most expensive thing in the hospital is a FY1 doctor (intern) with a pen” and “What’s the poison FY1s prescribe every day? [*awkward silence*] GENTAMICIN!” Most pragmatic docs and pharmacists here will teach that a SINGLE dose of 2-5mg/kg will rarely cause significant nephrotoxicity but further doses require trough gentamicin levels to avoid it.
That's a good question - unfortunately, I don't think there is consensus on this. Where I practice, most ID docs seem to prefer a "line holiday" (i.e. a period of several days in which the patient is without a CVC at all while the infection is treated with antibiotics given through peripheral IVs), but there are some who feel this is not necessary. It also depends on how critical central access is for other reasons (e.g. pressors, hemodynamic monitoring, etc...)
Dr. Strong, You are amazing, I used to be worried you would sell out one day! I hope you never feel that you have to! I get happy every time I see you are still contributing to the world "just because". Your name will be remembered in history as one of the greatest educators! You are my role model!
To the point lectures- really gain a lot of clinical knowledge from these lectures and experiences
Would love if you could update the antibiotic lectures from 9-10 years ago. Recently, also viewing the ID podcasts from Mofett. AGAIN THANK YOU!
Thanks! I know those antibiotic videos are in dire need of a revision. It's just impossible to find time to make all of the videos I'd like to.
Such an intresting topic to talk about. It's also perfectly organized. Thank you so much :)
Thank you Dr Strong .
Still remember first being on call as a medical intern and I was being slammed with quite a few neutopenic fevers. Wish I had this!!!
Excellent video, Dr. Strong.
Hello Dr. Strong, here a big fan of your work. Please consider a serie on chronic kidney disease, that would be
Thanks for the suggestions for videos on CKD. I haven't directly covered it as of yet because it's a little more outside the scope of my practice than most of the topics here, and will require a bit more reading on my part before feeling like I have something to add to the resources that are already out there. But it is on my list of topics I'd like to cover.
@@StrongMed Yes, also it is a very intricate and arid subject. I mean, it is very fun to study because a very rich pathophysiology and management, but it is a lot.
Thank you for the great information
My question is should we use anti pyretics or not as its my affect the follow-up
Thanks
Thank you!!
Couple of questions
1) Is there any way to predict the duration of neutropenia with somewhat reliable accuracy?
2) Is there any particular bacteria we're concerned about in severe cases, so much so that we're empirically adding FQ or aminoglycosides? Aren't vancomycin and Zosyn broad enough?
1. There are some general trends seen with specific chemotherapy regimens. For example, neutropenia is most severe and most prolonged in patients undergoing the pre-engraftment phase of hematopoietic cell transplantation, or those undergoing induction chemotherapy for acute leukemia. There are more specific rules-of-thumb about anticipated duration from specific chemo regimens - unfortunately I can't find a good reference to direct you to at the moment. Also, *in general* the risk factors for prolonged neutropenia, severe neutropenia, and neutropenic fever have much overlap.
2. The reasons for adding either a FQ or AG to the anti-pseudomonal beta-lactam is usually given as a combination of the possibility of Pseudomonas resistance to the beta lactam, and in vitro studies showing more rapid bacterial killing with combination therapy as compared to beta-lactam monotherapy (though with the tradeoff of more drug toxicity when used in actual people!) As I mentioned in the video, where I practice I have never personally seen a beta-lactam + empiric AG used for neutropenic fever. When double coverage of Pseudomonas is thought to be important, I've always seen beta-lactam + either cipro or levo used. However, antibiotic resistance patterns change over time and are not consistent across geography, so if local ID docs recommend something different where you practice, I would go with them.
Gracias
Do you start empiric antibiotics before you receive the neutrophile count to see if the patient is actually neuotropenic, or should you start it right after cultures are drawn if the patient has fever?
It would depend on the situation - specifically, what is the probability the patient is neutropenic, and how long will it take for the neutrophil count to be reported by the lab. I'd say in almost cases, for a patient undergoing chemotherapy who comes in to the ER for a fever (or other infectious symptoms), if the timing of the fever is concurrent with when neutropenia might be expected, I'd start antibiotics as soon as cultures are drawn (i.e. not waiting for the neutrophil count). In other words, I'd only wait for the neutrophil count if the pretest probability for neutropenia was low - unless the neutrophil count was going to take many hours to be reported. In general, the benefit of giving antibiotics quickly in a patient with neutropenic fever is much greater than the harm of giving a single dose of antibiotics to a patient who doesn't need it.
@@StrongMed Thanks!
Oof that solid tumor or no previous fungal infection for 4 points is an interesting and rough one. I’m guessing that’s because of fungal infections tendency to pop up later and the continuous nature of liquid tumor chemotherapy
Hi Dr Strong, another great video as usual!
After doing my Haematology/Oncology job I now routinely ask patients about perianal pain/rectal pain due to being caught out by patients with prolonged neutropenic sepsis due to what seemed like a forgettable symptom, but on MRI demonstrated neutropenic proctitis and anal fistula. Are perianal and rectal sources of neutropenic infection something you’ve unexpectedly encounted as well?
Also, with regards to aminoglycosides it’s very common in the UK to use Gentamicin as the sepsis “panic button” for double coverage of gram -ve organisms. E.g “if deteriorates give STAT dose of 5mg/kg gent”
Thanks for mentioning these points! Regarding, perianal/rectal sources for neutropenic fever, I have also heard this from others but have not personally seen it myself - though if you specifically work on a heme/onc service, you probably have a much greater sample size on this than I do being on a gen med service. With AGs, in the US physicians seem particularly apprehensive about the associated renal toxicity - leading to a discordance between expert recommendations and common practice (with both neutropenic fever, and in other circumstances as well).
@@StrongMed The renal toxicity is definitely a thing geriatricians and nephrologists love to complain about over here! Common lines like “the most expensive thing in the hospital is a FY1 doctor (intern) with a pen” and “What’s the poison FY1s prescribe every day? [*awkward silence*] GENTAMICIN!” Most pragmatic docs and pharmacists here will teach that a SINGLE dose of 2-5mg/kg will rarely cause significant nephrotoxicity but further doses require trough gentamicin levels to avoid it.
Thanks alot doctor
Is removal of CVC indicated in bloodstream infection with CVC insertion in another location or complete removal until bacteraemia is resolved?
That's a good question - unfortunately, I don't think there is consensus on this. Where I practice, most ID docs seem to prefer a "line holiday" (i.e. a period of several days in which the patient is without a CVC at all while the infection is treated with antibiotics given through peripheral IVs), but there are some who feel this is not necessary. It also depends on how critical central access is for other reasons (e.g. pressors, hemodynamic monitoring, etc...)
How about voriconazole, empiric antifungal cover
Celcius? Can you state that in american please?