MCQ Quiz: Neutropenic Fever

Neutropenic fever is one of the most common and life-threatening oncologic emergencies, requiring immediate medical attention and prompt initiation of empiric antibiotic therapy. For pharmacists, managing patients with neutropenic fever is a critical responsibility that involves risk stratification, appropriate antimicrobial selection, and careful monitoring to optimize outcomes and ensure patient safety. A deep understanding of the definitions, risk factors, and evidence-based guidelines from organizations like the IDSA and NCCN is essential. This quiz is designed for PharmD students to test their knowledge on the diagnosis and complex pharmacotherapy involved in managing this serious complication of cancer treatment.

1. Neutropenia is defined as an Absolute Neutrophil Count (ANC) of less than:

• a) 2,000 cells/mm³
• b) 1,500 cells/mm³
• c) 1,000 cells/mm³
• d) 500 cells/mm³

Answer: d) 500 cells/mm³

2. A patient receiving chemotherapy has a WBC count of 1.2 x 10³/mm³ with 30% segmented neutrophils and 5% bands. What is their ANC?

• a) 360 cells/mm³
• b) 420 cells/mm³
• c) 600 cells/mm³
• d) 1200 cells/mm³

Answer: b) 420 cells/mm³

3. In the context of neutropenia, a fever is defined as a single oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) sustained for at least:

• a) 30 minutes
• b) 1 hour
• c) 2 hours
• d) 4 hours

Answer: b) 1 hour

4. The MASCC (Multinational Association for Supportive Care in Cancer) score is used to:

• a) Determine the type of cancer a patient has.
• b) Predict the duration of neutropenia.
• c) Identify low-risk patients with neutropenic fever who may be candidates for outpatient management.
• d) Calculate the appropriate dose of chemotherapy.

Answer: c) Identify low-risk patients with neutropenic fever who may be candidates for outpatient management.

5. A high-risk patient with febrile neutropenia requires admission and IV antibiotics. Which of the following factors would classify a patient as high-risk?

• a) Anticipated short duration of neutropenia (<7 days).
• b) No significant comorbidities.
• c) A high MASCC score (≥21).
• d) Profound neutropenia (ANC <100 cells/mm³) and significant comorbidities.

Answer: d) Profound neutropenia (ANC <100 cells/mm³) and significant comorbidities.

6. What is the cornerstone of initial empiric therapy for a high-risk inpatient with febrile neutropenia?

• a) Oral amoxicillin
• b) IV vancomycin monotherapy
• c) IV anti-pseudomonal beta-lactam monotherapy
• d) IV daptomycin

Answer: c) IV anti-pseudomonal beta-lactam monotherapy

7. Which of the following is an appropriate first-line empiric antibiotic choice for a high-risk febrile neutropenia patient?

• a) Ceftriaxone
• b) Cefepime
• c) Cephalexin
• d) Ertapenem

Answer: b) Cefepime

8. Vancomycin should be added to the initial empiric regimen for febrile neutropenia if which of the following is present?

• a) The patient has a low-grade fever.
• b) The patient has suspected catheter-related infection, skin/soft tissue infection, or hemodynamic instability.
• c) The patient’s ANC is >500 cells/mm³.
• d) Vancomycin should always be started empirically in all patients.

Answer: b) The patient has suspected catheter-related infection, skin/soft tissue infection, or hemodynamic instability.

9. For a low-risk patient with febrile neutropenia who can be managed as an outpatient, a common oral empiric regimen is:

• a) Amoxicillin alone
• b) Ciprofloxacin plus amoxicillin-clavulanate
• c) Metronidazole alone
• d) Oral vancomycin

Answer: b) Ciprofloxacin plus amoxicillin-clavulanate

10. A patient with a documented history of a severe penicillin allergy (anaphylaxis) presents with high-risk febrile neutropenia. A suitable empiric regimen would be:

• a) Piperacillin-tazobactam
• b) Cefepime
• c) Ciprofloxacin plus clindamycin or aztreonam plus vancomycin.
• d) Meropenem

Answer: c) Ciprofloxacin plus clindamycin or aztreonam plus vancomycin.

11. After initiating empiric antibiotics for febrile neutropenia, when should the patient be reassessed for response?

• a) After 1 hour
• b) After 12 hours
• c) After 2 to 4 days
• d) After 1 week

Answer: c) After 2 to 4 days

12. If a febrile neutropenic patient remains febrile after 4-7 days of broad-spectrum antibiotics and has an anticipated prolonged duration of neutropenia, what is the next step?

• a) Stop all antibiotics.
• b) Add empiric antifungal coverage.
• c) Double the dose of the current antibiotic.
• d) Switch to oral antibiotics.

Answer: b) Add empiric antifungal coverage.

13. Which of the following is the most common cause of bloodstream infections in neutropenic cancer patients?

• a) Viruses
• b) Fungi
• c) Gram-negative bacteria
• d) Gram-positive bacteria (from skin flora or central lines)

Answer: d) Gram-positive bacteria (from skin flora or central lines)

14. Prophylactic use of granulocyte colony-stimulating factors (G-CSFs) like filgrastim is recommended for primary prevention in patients receiving a chemotherapy regimen with a ≥20% risk of:

• a) Tumor lysis syndrome
• b) Hypercalcemia
• c) Febrile neutropenia
• d) CINV

Answer: c) Febrile neutropenia

15. What is the main difference between filgrastim (Neupogen®) and pegfilgrastim (Neulasta®)?

• a) Filgrastim is more potent.
• b) Pegfilgrastim has a longer half-life, allowing for a single dose per chemotherapy cycle.
• c) Filgrastim is administered orally.
• d) Pegfilgrastim is used to treat anemia.

Answer: b) Pegfilgrastim has a longer half-life, allowing for a single dose per chemotherapy cycle.

16. What is a common and expected side effect of G-CSF therapy?

• a) Alopecia
• b) Bone pain
• c) Severe nausea
• d) Constipation

Answer: b) Bone pain

17. The use of G-CSF for the treatment of established neutropenic fever is:

• a) Recommended for all patients.
• b) Generally not recommended as it has not been shown to improve survival.
• c) The first-line therapy.
• d) Only indicated for low-risk patients.

Answer: b) Generally not recommended as it has not been shown to improve survival.

18. What is the most critical first action a pharmacist should take when a patient calls reporting a fever while on chemotherapy?

• a) Recommend acetaminophen and tell them to call back tomorrow.
• b) Advise them to immediately contact their oncologist or go to the emergency department for evaluation.
• c) Suggest they take their temperature again in a few hours.
• d) Ask them about their dietary intake.

Answer: b) Advise them to immediately contact their oncologist or go to the emergency department for evaluation.

19. Which of the following is an anti-pseudomonal carbapenem that can be used for high-risk febrile neutropenia?

• a) Ertapenem
• b) Meropenem
• c) Doripenem
• d) Both B and C

Answer: d) Both B and C

20. A patient’s ANC is calculated by multiplying the total WBC count by the percentage of:

• a) Lymphocytes plus monocytes.
• b) Eosinophils plus basophils.
• c) Segmented neutrophils plus bands.
• d) Red blood cells.

Answer: c) Segmented neutrophils plus bands.

21. A patient with febrile neutropenia has their blood cultures come back positive for Pseudomonas aeruginosa. The initial empiric antibiotic was cefepime. What is the next step?

• a) Stop the cefepime and observe.
• b) Continue cefepime and tailor therapy based on the final susceptibility report.
• c) Immediately add vancomycin and metronidazole.
• d) Switch to oral ciprofloxacin.

Answer: b) Continue cefepime and tailor therapy based on the final susceptibility report.

22. Antifungal prophylaxis with an agent covering molds (e.g., posaconazole) is recommended for which high-risk patient population?

• a) All patients receiving chemotherapy for breast cancer.
• b) Patients undergoing induction chemotherapy for acute myeloid leukemia (AML).
• c) All patients with a low MASCC score.
• d) All patients over the age of 65.

Answer: b) Patients undergoing induction chemotherapy for acute myeloid leukemia (AML).

23. Why is it important to perform a thorough physical exam on a neutropenic patient with a fever?

• a) To identify a potential source of infection (e.g., line site, mucositis, perirectal area).
• b) Because the classic signs of inflammation (redness, swelling, pus) may be absent.
• c) To guide the choice of empiric antibiotics.
• d) All of the above.

Answer: d) All of the above.

24. Prophylaxis with a fluoroquinolone (e.g., levofloxacin) may be considered in which high-risk cancer patients?

• a) All patients receiving any type of chemotherapy.
• b) Patients expected to have profound, prolonged neutropenia (ANC <100 for >7 days).
• c) Patients receiving only radiation therapy.
• d) It is never recommended due to resistance concerns.

Answer: b) Patients expected to have profound, prolonged neutropenia (ANC <100 for >7 days).

25. A febrile neutropenic patient is hemodynamically unstable (hypotensive). The empiric antibiotic regimen should:

• a) Be a single oral agent.
• b) Be a broad-spectrum combination, often including an anti-pseudomonal beta-lactam plus an aminoglycoside or a second gram-negative agent.
• c) Focus only on gram-positive coverage.
• d) Be delayed until the blood pressure stabilizes.

Answer: b) Be a broad-spectrum combination, often including an anti-pseudomonal beta-lactam plus an aminoglycoside or a second gram-negative agent.

26. Severe neutropenia is defined as an ANC less than:

• a) 1000 cells/mm³
• b) 500 cells/mm³
• c) 200 cells/mm³
• d) 100 cells/mm³

Answer: b) 500 cells/mm³

27. What is the most common portal of entry for infection in neutropenic patients?

• a) The respiratory tract.
• b) The gastrointestinal tract, due to chemotherapy-induced mucositis.
• c) The urinary tract.
• d) The central nervous system.

Answer: b) The gastrointestinal tract, due to chemotherapy-induced mucositis.

28. If a patient is discharged on an oral antibiotic regimen for low-risk febrile neutropenia, what is a critical counseling point?

• a) The importance of returning for follow-up within 24-72 hours.
• b) Instructions on when to seek immediate medical attention if symptoms worsen.
• c) To complete the full course of antibiotics as prescribed.
• d) All of the above.

Answer: d) All of the above.

29. The duration of antibiotic therapy for neutropenic fever is typically continued until:

• a) The fever resolves for 24 hours.
• b) The blood cultures are negative.
• c) The full 14-day course is complete, regardless of other factors.
• d) The patient is no longer neutropenic (e.g., ANC > 500 cells/mm³) and is afebrile.

Answer: d) The patient is no longer neutropenic (e.g., ANC > 500 cells/mm³) and is afebrile.

30. Why is ertapenem generally not a preferred monotherapy agent for high-risk febrile neutropenia?

• a) It has poor gram-positive coverage.
• b) It has an unacceptably high rate of nephrotoxicity.
• c) It lacks reliable activity against Pseudomonas aeruginosa.
• d) It is only available as an oral formulation.

Answer: c) It lacks reliable activity against Pseudomonas aeruginosa.

31. Prophylactic antiviral therapy (e.g., acyclovir) should be considered in neutropenic patients who are:

• a) At risk for influenza.
• b) Seropositive for Herpes Simplex Virus (HSV) and undergoing intensive chemotherapy or stem cell transplant.
• c) Receiving G-CSF therapy.
• d) All neutropenic patients.

Answer: b) Seropositive for Herpes Simplex Virus (HSV) and undergoing intensive chemotherapy or stem cell transplant.

32. A patient with a documented MRSA infection who develops febrile neutropenia should have which antibiotic included in their empiric regimen?

• a) Metronidazole
• b) Vancomycin or Linezolid
• c) Cefazolin
• d) Ampicillin

Answer: b) Vancomycin or Linezolid

33. The single most important risk factor for developing an infection in a cancer patient is the:

• a) Type of cancer.
• b) Patient’s age.
• c) Severity and duration of neutropenia.
• d) Patient’s diet.

Answer: c) Severity and duration of neutropenia.

34. The primary goal of managing neutropenic fever is to:

• a) Prevent hair loss.
• b) Reduce the cost of care.
• c) Prevent infection-related morbidity and mortality.
• d) Eliminate the need for future chemotherapy.

Answer: c) Prevent infection-related morbidity and mortality.

35. A patient on outpatient therapy for low-risk febrile neutropenia calls to report they developed a rash and difficulty breathing after taking their first dose of amoxicillin-clavulanate. The pharmacist should advise them to:

• a) Take another dose to see if the reaction subsides.
• b) Take an over-the-counter antihistamine and continue the antibiotic.
• c) Seek immediate emergency medical attention.
• d) Switch to the ciprofloxacin monotherapy.

Answer: c) Seek immediate emergency medical attention.

36. A patient with a central venous catheter (CVC) has febrile neutropenia, and blood cultures drawn from the CVC grow bacteria 2 hours before cultures from a peripheral vein. This suggests:

• a) The sample was contaminated.
• b) The patient has a UTI.
• c) The CVC is the likely source of the infection.
• d) The infection is likely viral.

Answer: c) The CVC is the likely source of the infection.

37. When is secondary prophylaxis with G-CSF indicated?

• a) After every cycle of chemotherapy.
• b) For a patient who experienced a neutropenic fever episode during a prior cycle of the same chemotherapy regimen.
• c) For all low-risk patients.
• d) It is never indicated.

Answer: b) For a patient who experienced a neutropenic fever episode during a prior cycle of the same chemotherapy regimen.

38. Which of the following is an important element of patient education to prevent infections while neutropenic?

• a) Thorough hand hygiene.
• b) Avoiding crowds and sick contacts.
• c) Proper food safety (e.g., avoiding raw foods).
• d) All of the above.

Answer: d) All of the above.

39. A patient is receiving piperacillin-tazobactam for febrile neutropenia. The pharmacist should ensure the dose is adjusted for:

• a) Hepatic dysfunction
• b) Renal dysfunction
• c) The patient’s age
• d) The patient’s gender

Answer: b) Renal dysfunction

40. Why is a thorough oral cavity exam important in a febrile neutropenic patient?

• a) To check for cavities.
• b) To identify chemotherapy-induced mucositis, which is a common infection portal.
• c) To assess their ability to swallow pills.
• d) To check their sense of taste.

Answer: b) To identify chemotherapy-induced mucositis, which is a common infection portal.

41. An appropriate empiric antifungal agent for a persistently febrile neutropenic patient at high risk for invasive mold infections is:

• a) Fluconazole
• b) Voriconazole or an echinocandin
• c) Nystatin swish and swallow
• d) Terbinafine cream

Answer: b) Voriconazole or an echinocandin

42. The term “profound neutropenia” refers to an ANC of less than:

• a) 1000 cells/mm³
• b) 500 cells/mm³
• c) 200 cells/mm³
• d) 100 cells/mm³

Answer: d) 100 cells/mm³

43. A patient with neutropenic fever should avoid which type of medication for their fever without consulting their oncology team?

• a) Acetaminophen
• b) Opioids
• c) NSAIDs (e.g., ibuprofen), due to antiplatelet effects and masking of fever.
• d) Antihistamines

Answer: c) NSAIDs (e.g., ibuprofen), due to antiplatelet effects and masking of fever.

44. If a febrile neutropenic patient develops severe diarrhea, the antibiotic regimen should be broadened to include coverage for which pathogen?

• a) MRSA
• b) Clostridioides difficile
• c) VRE
• d) Candida albicans

Answer: b) Clostridioides difficile

45. What is the most common dose-limiting toxicity of conventional cytotoxic chemotherapy?

• a) Cardiotoxicity
• b) Nephrotoxicity
• c) Myelosuppression
• d) Neurotoxicity

Answer: c) Myelosuppression

46. A patient has a MASCC score of 19. This indicates:

• a) High risk for complications, requiring inpatient management.
• b) Low risk for complications, and outpatient management may be considered.
• c) A definitive fungal infection.
• d) The need to add vancomycin.

Answer: b) Low risk for complications, and outpatient management may be considered.

47. A pharmacist ensures a patient receiving high-dose chemotherapy understands their G-CSF administration schedule. This intervention is an example of:

• a) Primary prophylaxis of febrile neutropenia.
• b) Treatment of febrile neutropenia.
• c) Secondary prophylaxis of febrile neutropenia.
• d) Management of bone pain.

Answer: a) Primary prophylaxis of febrile neutropenia.

48. Why is it important to obtain blood cultures before administering the first dose of empiric antibiotics?

• a) It is not important.
• b) To ensure the antibiotics do not interfere with the culture results, which helps guide future therapy.
• c) To increase the patient’s anxiety.
• d) To confirm the patient has an infection before treating.

Answer: b) To ensure the antibiotics do not interfere with the culture results, which helps guide future therapy.

49. De-escalation of antibiotics in a febrile neutropenic patient is appropriate when:

• a) The patient’s fever has resolved, but they are still profoundly neutropenic.
• b) A specific pathogen has been identified, and therapy can be narrowed based on susceptibilities.
• c) The patient requests a less potent antibiotic.
• d) It is never appropriate to de-escalate.

Answer: b) A specific pathogen has been identified, and therapy can be narrowed based on susceptibilities.

50. The prompt management of neutropenic fever is critical because:

• a) It can rapidly progress to severe sepsis and septic shock without a robust immune response to contain the infection.
• b) It causes significant patient discomfort.
• c) It is a quality measure tracked by hospitals.
• d) It always requires a 14-day hospital stay.

Answer: a) It can rapidly progress to severe sepsis and septic shock without a robust immune response to contain the infection.