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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

definition of pyrexia
Definition of Pyrexia
  • Oral or tympanic membrane temperature of >38C
  • Note fever may not be present in patients who are dehydrated, on steroids or NSAIDs and the possibility of infection must be considered in any unwell neutropenic patient
  • Fever may also occur as a complication of transfusion, drugs, or be a symptom of cancer i.e. lymphoma, renal cell carcinoma
definition neutropenic fever
Definition- Neutropenic Fever

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

definition neutropenic sepsis
Definition- Neutropenic Sepsis

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 at risk of neutropenic fever and sepsis
Patients at risk of neutropenic fever and sepsis

Patients receiving chemotherapy for malignant disease

Particularly between 5 and 28 days after receiving cytotoxic chemotherapy

Patients with haematological conditions associated with neutropenia

Leukeamia

Lymphoma

Myelodysplasia

Patient receiving other drugs associated with neutropenia

Patients with neutropenia due to other causes

chemotherapy and neutropenia
Chemotherapy and neutropenia

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

management of neutropenic fever
Management of Neutropenic fever

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

in eau
In EAU

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.

HYPOTENSION

TACHYCARDIA

If the signs of sepsis are not present the patient should be managed on the NEUTROPENIC FEVER CARE PATHWAY.

neutropenic care pathway
Neutropenic 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

.

door to needle time 4 hours
Door to Needle Time < 4 hours

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.

care pathway
CARE PATHWAY

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

history
History

Symptoms to point to source of infection

Eg. Cough, dysuria, hickman line, skin, mouth, ENT, GU symptoms, diarrhoea,

Co-morbid disease

Treatment history

Cancer diagnosis, stage, prior treatment, date of last treatment

Drug history

Antibiotics, drugs known to cause neutropenia, number of days since chemotherapy

examination
Examination

Signs of infection?

Respiratory,

Hickman line site,

Skin,

Abdominal,

CNS,

oral cavity

Do not perform a PR

This may cause addition sepsis in the neutropenic patient

slide15

IN MOST PATIENTS A SCOURCE OF INFECTION IS NOT FOUND but does not exclude an infective diagnosis

    • Gram negative sepsis occurs from patients own bowel flora
investigations on admission
Investigations on admission

Blood cultures

If the patient has a hickman or PICC line take cultures from both line and peripherally (direct from vein).

U+E

Septic patients may develop renal failure

Gentamycin is renally toxic

CRP

MSU

FBC

Blood gases if septic or hypoxic

CXR

g csf
G-CSF

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

high risk patients are at risk of progressing from neutropenic fever to sepsis
High risk patients are at risk of progressing from neutropenic fever to sepsis

This Includes

Patients with haematological malignancy

Leukeamia, Lymphoma, myeloma,

Patients with uncontrolled solid tumours

Cancer symptoms,

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

management of high risk patients on admission
Management of High Risk Patients on Admission

High risk patients require

IV fluids

Regular pulse and BP

Regular medical review

Specialist Oncology/Heamatology review within 24 hours of admission.

In addition to prompt antibiotic therapy.

high risk or low risk of developing neutropenic sepsis
High Risk or Low Risk of Developing Neutropenic sepsis?

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.

next day
Next day

Examine patient

cardiovascular stability

Gentamycin levels

Check FBC

Check U+Es

Review fluid requirements

Contact oncology/heamatology team if this has not already been done.

neutropenic sepsis
NEUTROPENIC SEPSIS

Patients with neutropenia plus tachycardia or hypotension are at high risk of death

Management of these patients is individualised according to need

management if neutropenic sepsis
MANAGEMENT IF NEUTROPENIC SEPSIS

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

where can i get help
Where can I get help?

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.