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Antibiotic Management of Neutropenic Sepsis at The James Cook University Hospital

Dr Katherine Watson ST1 Microbiology. Antibiotic Management of Neutropenic Sepsis at The James Cook University Hospital. Introduction. Review of trust antibiotic policy using:

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Antibiotic Management of Neutropenic Sepsis at The James Cook University Hospital

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  1. Dr Katherine Watson ST1 Microbiology Antibiotic Management of Neutropenic Sepsis atThe James Cook University Hospital

  2. Introduction • Review of trust antibiotic policy using: • Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients. NICE Guidelines,September 2012 • Local antibiotic resistance rates in gram negative bacteraemias

  3. NICE Guidelines • All patients should be offered: • Prophylaxis with fluoroquinolone antibiotics during expected periods of neutropenia • Piperacillin/tazobactam as initial empiric antibiotic therapy • Aminoglycosides not recommended • “Unless patient specific or local microbiological contraindications”

  4. Current Trust Antibiotic Policy • Neutrophil count < 1.0 x 10 9 /L plus any of the following: • Temp. > 38oC at any time • Rigors • Hypothermia • Unexplained hypotension • Unexplained deterioration without pyrexia • Patients must receive intravenous antibiotics within 1 hour of presentation • First Line Antibiotic (pending culture results) Piperacillin/Tazobactam 4.5g tds • + Gentamicin 5mg/kg stat

  5. Methods • APEX search • Positive blood cultures for patients under care of haematology consultants • Information recorded: • Organism identification • Antibiotic sensitivities of gram negative bacteria • Piperacillin/tazobactam, meropenem, ciprofloxacin, gentamicin

  6. Positive Blood Cultures • 512 positive blood culture bottles taken between February 2009 and October 2012 • 151 patients • 600 organisms cultured • 267 gram positive bacteria (44.5%) • 329 gram negative bacteria (54.8%) • 4 fungi (0.7%)

  7. Bacteria Identified • 329Gram negative bacteria: • 108E.coli 33.0% • 103KESC group 31.3% • 60Pseudomonas sp. 18.2% • 23Stenotrophomonas maltophilia 6.9% • 11Acinetobacter sp. 3.3% • 24Other gram negative bacteria 7.3%

  8. Antibiotic Resistance S=sensitive, R= resistant. Not all organisms have full sensitivities available on APEX, S. Maltophilia not included as poor correlation between antibiotic susceptibility and treatment outcome

  9. 1. Fluoroquinolone Prophylaxis • However concerns regarding: • Risk of antibiotic associated Clostridium difficile • Development of antibiotic resistance • Action • Use of fluoroquinolone prophylaxis still under consideration • 94% of gram negative bacteria sensitive to ciprofloxacin

  10. 2. Piperacillin/tazobactam • 35 piperacillin/tazobactam resistant gram negative bacteria • 12 individuals, 2 with recurrent bacteraemias • Action • Continue to use as part of first line treatment of neutropenic sepsis • Not to use as a single agent • Local resistant rate of 12% in gram negative bacteria

  11. 3. Aminoglycosides • Only 2 bacteraemias resistant to both piperacillin/tazobactam and gentamicin • Action • Gentamicin will continue to be given for at least the first 24 hours after admission • To be reviewed with clinical response and culture results • 99.2% of gram negative bacteria sensitive to either piperacillin/tazobactam or gentamicin

  12. Conclusion • First line treatment of neutropenic sepsis to remain as piperacillin/tazobactam and gentamicin • High resistance rates to NICE recommended empiric agent • NICE guidelines comment on importance of local resistance patterns • “High rates of resistance to chosen empiric agent could lead to treatment failure”

  13. Any Questions? Katherine.watson@stees.nhs.uk

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