Management of neutropenic sepsis

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The guidelines are aimed at health care professionals who may not come into contact with neutropenic patients on a regular basis but who will be expected to triage and commence emergency care for this patient group. The guidance is there to compliment existing local policy.

Neutropenic sepsis is a medical emergency. Neutropenic sepsis can occur with a neutrophil count <1.0×109/L.

Contents

Categories of patient are at high risk of neutropenic sepsis

  1. Those who have received recent cytotoxic chemotherapy (within last 3 months).
  2. OR

  3. Those diagnosed with a haematological malignancy such as acute lymphoblastic or myeloblastic leukaemia (ALL, AML).
  4. OR

  5. Bone marrow failure syndrome.

Any patient who presents with any of the above criteria

AND

  1. Has a fever of 38oC.
    • Note: fever may be suppressed if patient on steroids.

    OR

  2. Who are generally unwell and showing signs of sepsis – hypotensive, breathlessness, and tachycardia.

must be assumed to have neutropenic sepsis and must be assessed by a doctor in a Hospital as an emergency.

Initial assessment

On arrival the patient should be assessed immediately as follows:

  • Temperature
  • Blood pressure
  • Pulse
  • Respiration rate
  • Oxygen saturation
  • Need for resuscitation appropriately including the use of intravenous fluids

Initial investigations

The following investigations should be undertaken but first line antibiotics and fluid replacement should not be deferred pending investigations. Antibiotics must start within one hour of presentation.

  • Urgent FBC (plus differential)
  • Clotting screen
  • U&Es, LFTs
  • Blood for culture and sensitivity
  • Swabs must include nose, throat, and peripheral and or central venous catheters if applicable including exit sites and obvious infected sites
  • MSU
  • Stool as soon as possible (daily if the patient has diarrhoea) checking particularly for clostridium difficile. (Avoid PR examinations as this may cause a peri-rectal abscess.)
  • Chest x-ray.

All patients MUST commence regular observations of temperature, pulse, respiration & blood pressure, oxygen saturation, monitoring of fluid intake and output, which initially may be quarter hourly and then reviewed when the patient’s condition improves.

First line antibiotics
Tazocin 4.5g TDS
Gentamicin once daily as per local policy
REFER TO LOCAL GENTAMICIN POLICY
Use cautiously in patients with Myeloma due to risk of renal failure
For penicillin allergic patients - as per local policy
Patients presenting with diarrhoea - add metronidazole 500mg TDS IV or PO

Following initial assessment and treatment by the medical team, who must then contact the on call haematology or oncology team for further advice on treatment, management and care.

The on-call haematology or oncology medical team should inform the appropriate medical team at the centre who may give further advise and support.

Ideally the patient should be admitted to the haematology or cancer ward so they can receive appropriate nursing care and expertise needed during this time of risk.

The patient must remain under the medical team and be formally handed over to the team the next day.

The subsequent changes of antibiotics if the fever fails to resolve must be in accordance with microbiological results and guidance as per local policy.

Local practice and amendments

First line therapy

  • Gentamicin 7mg/kg over 1 hour in 100mls normal saline once daily
  • Tazobactam 4.5gms TDS if patient >50kg; if <50kg 90mg/kg TDS

Second line therapy (and penicillin allergy)

  • Ceftazidime 2g TDS (caution if anaphylaxis or allergy to penicillin)
  • Teicoplanin 400mg BD for 3 doses and then 200mg daily
  1. Check renal function re. gentamicin: if creatinine >200μmol/L use 5mg/kg
  2. Check gentamicin level between 6-14 hours after the start of the IV infusion and refer to nomogram for further dosing.
  3. Admit patient to Laurel Ward (side room).
  4. For advice re. neutropenic sepsis contact Specialist Registrar Haematology or Haematology Consultant.

Policy for neutropenic haematology patients

Following the administration of chemotherapy patients are at risk of neutropenia. This usually occurs 7-10 days post administration of chemotherapy.

A full blood count will ascertain the severity of neutropenia.

Management

  • If neutrophils are <1.0×109/L and patients are pyrexial they will be admitted to Laurel Ward and be isolated.
  • They should commence IV Tazocin 4.5g and gentamicin; if pyrexial this must be given within one hour of the patient presenting. The instructions of the haematology team should then be followed.
  • A full septic screen will be required; swabs are to be taken from throat, central line sites (Hickman line/PICC line site) and any open wounds. Patients will also require blood cultures. If they have a central line these must be taken peripherally and from the line.
Neutrophil count Actions
>10×109/L Assess patient for active infection.
Ascertain whether taking steroids or GCSF.
Regardless of symptoms consult medical staff and document in patient's medical notes. Act upon medical instruction.
1-10×109/L No action unless symptomatic
0.5-1.0×109/L Take baseline observations BP, P and Temp. Consult medical staff for further instructions.
Following a nursing assessment if asymptomatic document in medical notes. Patient may require oral ciprofloxacin, fluconozole, mouth care +/- GCSF.
If patients are symptomatic of infection, or have a temperature of 38oC or above admit immediately to Laurel Ward as a priority is necessary. Discuss with medical staff and arrange appropriate intervention. Complete full septic screen: swab throat, central lines (Hickman line/PICC line site) and any open wounds. Commence IV antibiotics. Isolate patient.
<0.5×109/L Take baseline observations BP, P and Temp and document. Take blood cultures from central lines and also take peripheral blood cultures. Send a full septic screen; swab throat, axilla, central lines (Hickman/PICC line site) and any open wounds. Commence IV antibiotics if pyrexial. Check renal function and any other relevant tests. Isolate patient.

Regardless of symptoms discuss with medical staff.
NB. Neutrophils <1.0×109/L advise on infection risk.

NB. The use of paracetamol and NSAIDs can mask any fever.


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