Neutropenic Sepsis

Question 1

when is neutropenia seen in chemotherapy

Answer 1

around day 7-14 of each 3-weekly cycle

- BUT can be seen up to 6 weeks post chemo

Question 2

what is a normal neutrophil count

Answer 2

> 1.5x10(9)

Question 3

when is an increased risk of infection noted

Answer 3

when neutrophils <1.0x10(9)

markedly increased at <0.5x10(9)

Question 4

what are symptoms of infections in neutropenic patients

Answer 4

feeling hot/feverish/cold/shivery
aching joints/muscles
flu like symptoms
focal infection - cough, sore throat, UTI, etc

Question 5

at what temperatures should patents seek medical assessment

Answer 5

one recording of >38.5 or <36
OR
two recording of >38.8 two hrs apart

Question 6

when can neutropenic fever be diagnosed

Answer 6

1. patient is febrile
2. neutrophil count <1.0x10(9)
3. no haem-dynamic compromise

Question 7

when can neutropenic sepsis be diagnosed

Answer 7

evidence of sepsis (eg hypotension, tachycardia)
AND
neutrophil count <1.0x10(9) (+/- fever)

Question 8

pathogenic causes of neutropenic sepsis (ie microbiology)

Answer 8

85% - endogenous flora (eg from gut, biliary, urinary tracts)

75% cases gram -ve bacilli

fungal in prolonged neutropenia (esp in haem malignancies)

Question 9

non-specific symptoms

Answer 9

anorexia
malaise
lethargy
sweats

Question 10

specific symptoms of infection

Answer 10

fever, chills, riggers

symptoms related to a focus of infection

Question 11

what should you ask in a systematic enquiry

Answer 11

Chest infection (eg cough)
GI tract (eg diarrhoea)
Urinary tract (eg dysuria)
CNS (eg headache)
Skin infections/abscesses
sore throat
recent interventions (eg dental)

Question 12

key examinations

Answer 12

temp
pulse
BP
O2 sats
resp rate
full exams of each system for infection source

Question 13

Investigations - bloods

Answer 13

FBC
UE
Liver function
CRP
Coagulation screen (DIC)
blood cultures

Question 14

Investigations - other

Answer 14

Bone profile
MSSU
stool culture (diarrhoea)
throat swab ([haryngitis)
sputum culture
skin swabs
CXR

other guided by clinical status - eg LP, CT, etc

Question 15

Management

Answer 15

supportive care - volume resus (colloid/crystalloid)

O2 therapy

mouth care

broad spectrum AB

G-CSP (granulocyte colony stimulating factor) to boost neutrophil count

Question 16

What antibiotics are used for NS - stage 1

Answer 16

Piperacillin/Tazobactam (tazocin) 4.5g IV every 6 hrs
+
Gentamicin 7mg/kg IV

mild penicillin allergy - replace Piper/tazo with Ceftazidime 2g IV every 8 hrs + gentamicin

severe penicillin allergy - vancomycin + gentamicin +/-metronidazole

Question 17

Monitoring

Answer 17

temp
pulse
BP
O2 sats
UO - catheter if hypotensive
check cultures to optimise AB
FBC, UE, CRP daily

Question 18

why might you transfer a NS patient to ITU

Answer 18

if hypotension does not resolve with supportive measures at ward level

Question 19

what are the stage 2 AB

Answer 19

meropenem 1g IV every 8 hours (unless cultures suggest otherwise)

Question 20

when should you switch from stage 1 to stage 2 AB

Answer 20

if patient is still febrile 48hrs after stage 1, or if patient is repaid deteriorating despite stage 1 AB

Question 21

how do you review fluid requirements

Answer 21

assess fluid intak/output
vital signs
clinical evidence of underselling/overfilling
UE

Question 22

how do you review response to AB therapy

Answer 22

temp
BP pulse
CRP
Neutrophil count

Question 23

How long should a NS patient be on an antibiotic course

Answer 23

minimun 3 days IV

Question 24

when can patients come off IV AB

Answer 24

if after a minimum of 3 days on IV they are improving and are no longer neutropenic - can switch to oral ciprofloxacin