Neutropenic Sepsis

Question 1

What what point during a 3 week cycle of chemo is a patient most likely to be neutropenic?

Answer 1

7-14 days

Question 2

What is the normal neutrophil count?

Answer 2

1.5x10^9

Question 3

What neutrophil count puts the patient at risk of infection?

Answer 3

1.0x10^9

Question 4

What neutrophil count puts the patient at serious risk of infection?

Answer 4

0.5x10^9

Question 5

What symptoms should a patient self screen for that indicate infection?

Answer 5

Hot and feverish 
Cold and shaky 
Aching joints or muscles
Flu-like symptoms 
Cough, sore throat
UTI symptoms

Question 6

What is the definition of neutropenic fever?

Answer 6

A febrile patient where the neutrophil count is less than 1

Question 7

What is the definition of neutropenic sepsis?

Answer 7

Diagnosed when there is evidence of sepsis ie tachycardia or hypotension in the presence of a neutrophil count less than 1 with or without fever

Question 8

What are 3 microbiological causes of neutropenic sepsis?

Answer 8

Endogenous flora - gut biliary or urinary

Question 9

What 4 non-specific symptoms indicate infection?

Answer 9

Anorexia
Malaise
Lethargy
Sweats

Question 10

What 3 infection symptoms should you be particularly aware of?

Answer 10

Fever
Chills/rigours
Those related to a specific infection

Question 11

Describe the systematic enquiry you should undertake

Answer 11

Chest - cough/sore throat 
GI - diarrhoea
UTI - dysuria/polyuria
CNS - headache
SKIN - abcess
Recent dental work

Question 12

What 6 bedside examinations are you going to do?

Answer 12

Temperature
Pulse
BP
o2 sats
Respiratory rate
Specific system examination

Question 13

What generic investigations are you going to send off?

Answer 13

FBC - LFT, U&E, none profile, CRP
Coagulation screen if DIC
Blood cultures 
MSSU 
Stool culture if diarrhoea 
Throat swab if oharyngitis
Sputum culture if productive cough 
Skin swab if infected lesion 
CXR

Question 14

What is your initial management?

Answer 14

Volume recess - NaCl + dextrose
Oxygen therapy
Mouthcare

Question 15

What is stage 1 antibiotic care?

Answer 15

Within 30 mins: broad spectrum antibiotics
Pipercillin/ Tazobactam(tazocin) 4.5g IV every 6 hours + Gentamicin 7,g/kg IV

If mild penicillin allergy – use Ceftazidime 2g IV every 8 hours plus Gentamicin 7mg/kg IV (with level taken to determine dosing interval)
If severe penicillin allergy – consider Vancomycin and Gentamicin +/- Metronidazole

Question 16

What us stage 2 antibiotic care?

Answer 16

Meropenem 1g IV every 8 hours unless the culture suggest and alternative regimen

Question 17

What would you change antibiotics?

Answer 17

Move to step to if the patient is still febrile after 48 house or if the patient is clinically deteriorating

Question 18

What is your ongoing management protocol?

Answer 18

Monitor response
Usually SEWS chart
Urine output - catheterise if hypotensive
Check for positive cultures, and optimise antibiotic therapy based on sensitivities
Monitor FBC, U and E and CRP daily
May require ITU transfer if hypotension does not resolve