Transcript Neutropenic Fever - The Royal Wolverhampton NHS Trust

Neutropenic Fever
New Cross Hospital Induction
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/mm3 will 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
 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
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
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 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
•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
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
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
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
 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
 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
 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
 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
 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
 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

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

CRP
MSU
FBC
Blood gases if septic or hypoxic
CXR
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
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
 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?
 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
 Examine patient
 cardiovascular stability



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
Gentamycin levels
Check FBC
Check U+Es
Review fluid requirements
Contact oncology/heamatology team if
this has not already been done.
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
 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?
 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.