New Cross Hospital Induction. Neutropenic Fever. For patients receiving chemotherapy all infective episodes must be treated seriously and treated urgently with antibiotics
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For patients receiving chemotherapy all infective episodes must be treated seriously and treated urgently with antibiotics
50-60% of febrile neutropenic patients will prove to have an infection and 16-20% of patients with a neutrophil count <100/mm3will have a bacteraemia usually with gram +ve cocci or gram –ve baccilli
Fungal infections tend to occur after patients have received broad spectrum antibiotics or after prolonged periods of neutropenia
Neutropenic Fever =Pyrexia in the presence of neutrophil count less than 1.0 x 109/l
Patients with neutropenic fever may rapidly develop neutropenic sepsis without prompt appropriate treatment
Neutropenic Sepsis = Hypotension ( systolic <100mmg/Hg) and or Tachycardia (pulse >100bpm) in the presence of a neutrophil count less than 1.0 x109/l and infection.
Patients with neutropenic sepsis will NOT necessarily have a fever
Patients with neutropenic sepsis have a HIGH MORTALITY WITHOUT PROMPT APPROPRIATE TREATMENT
Patients receiving chemotherapy for malignant disease
Particularly between 5 and 28 days after receiving cytotoxic chemotherapy
Patients with haematological conditions associated with neutropenia
Patient receiving other drugs associated with neutropenia
Patients with neutropenia due to other causes
In patients receiving chemotherapy for solid tumours the white count nadir most commonly occurs 7-14 days after chemotherapy has been given. In the treatment of solid tumours is usually short lived and recovers spontaneously within 7 days. However patients may be at risk of a febrile neutropenic event at any time throughout the chemotherapy cycle.
Patients receiving chemotherapy for haematological malignancy i.e. leukaemia or lymphoma may have a deeper and longer lasting period of neutropenia and may be at high risk of developing neutropenic sepsis
Patients at risk of neutropenia presenting to EAU or A+E with pyrexia should be treated as an emergency and should be triaged as RED
These patients include
those within 5 – 28 days after delivery of cytotoxic chemotherapy
Do NOT wait for blood tests to confirm neutropenia as this may waste valuable time.
Treat with intravenous antibiotics immediately and
assess for signs of sepsis i.e.
If the signs of sepsis are not present the patient should be managed on the NEUTROPENIC FEVER CARE PATHWAY.
The Oncology or Heamatology Team on call should be contacted to inform them of the admission.
Commence Tazocin and Gentamycin immediately without waiting for results of FBC or cultures
If the patient is not neutropenic the antibiotic regime may be altered later
When possible take blood cultures prior to giving antibiotics but do not delay the antibiotic therapy
Antibiotic therapy should be given WITHIN 4 hours of the patient entering the hospital
It is the admitting doctor’s responsibility to ensure that intravenous antibiotics are given promptly.
COMMENCE ALL PATIENTS WITH NEUTROPENIC FEVER ON THE NEUTROPENIC FEVER CARE PATHWAY FOR THE FIRST 48 HOURS OF ADMISSION.
FOLLOW MANAGEMENT AS DICTATED BY THE CAREPATHWAY
Symptoms to point to source of infection
Eg. Cough, dysuria, hickman line, skin, mouth, ENT, GU symptoms, diarrhoea,
Cancer diagnosis, stage, prior treatment, date of last treatment
Antibiotics, drugs known to cause neutropenia, number of days since chemotherapy
Signs of infection?
Hickman line site,
Do not perform a PR
This may cause addition sepsis in the neutropenic patient
IN MOST PATIENTS A SCOURCE OF INFECTION IS NOT FOUND but does not exclude an infective diagnosis
If the patient has a hickman or PICC line take cultures from both line and peripherally (direct from vein).
Septic patients may develop renal failure
Gentamycin is renally toxic
Blood gases if septic or hypoxic
G-CSF ( granulocyte colony stimulating factor) has no role in the acute management of uncomplicated neutropenic fever
G-CSF is a consultant only prescription drug at New Cross Hospital
Patients with haematological malignancy
Leukeamia, Lymphoma, myeloma,
Patients with uncontrolled solid tumours
Patients receiving chemotherapy with palliative intent
Patients with significant concomitant medical conditions
i.e. CCF, COAD
Patients aged over 65
Patients already on antibiotics
Patients with an identifiable infective focus
e.g. LRTI, UTI
High risk patients require
Regular pulse and BP
Regular medical review
Specialist Oncology/Heamatology review within 24 hours of admission.
In addition to prompt antibiotic therapy.
When in doubt ALWAYS assume the patient is at HIGH risk of neutropenic sepsis
The oncology team will determine the risk category and commence patients on the low risk pathway if appropriate.
Review fluid requirements
Contact oncology/heamatology team if this has not already been done.
Patients with neutropenia plus tachycardia or hypotension are at high risk of death
Management of these patients is individualised according to need
ALL PATIENTS REQUIRE IMMEDIATE ANTIBIOTIC THERAPY
ALL PATIENTS REQUIRE IMMEDIATE AND AGGRESSIVE FLUID RESUSSITATION
IF THE PATIENT FAILS TO RESPOND TO INITIAL FLUID RESUSITATON HDU/ITU ADMISSION MUST BE CONSIDERED
REGULAR OBSERVATIONS ARE MANATORY, IMMEDIATE ACTION IS REQUIRED IN THE EVENT OF CARDIOVASCULAR INSTABILITY
THE ONCOLOGY/HEAMATOLOGY TEAM MUST BE INFORMED
The oncologist or heamatologist on-call is available though switch-board. 24hr advice is available.
Dial 0 and ask to speak to the on-call oncologist or heamatologist
The neutropenic care pathway document ( hard copy) is available in EAU, CHU, Deanesly ward and Durnall suite. It is also available to print off directly from the Intranet
Advice on neutropenic fever, neutropenic sepsis and other oncological emergencies are available on the intranet.