New Cross Hospital Induction Neutropenic Fever. For patients receiving chemotherapy all infective episodes must be treated seriously and treated urgently.

New Cross Hospital InductionNew Cross Hospital Induction

Neutropenic FeverNeutropenic Fever

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 PyrexiaDefinition of Pyrexia

Oral or tympanic membrane temperature of >38Oral or tympanic membrane temperature of >38CC

• Note fever may not be present in patients who Note fever may not be present in patients who are are dehydrated, on steroids or NSAIDs and the dehydrated, on steroids or NSAIDs and the possibility of infection must be considered in any possibility of infection must be considered in any unwell neutropenic patientunwell neutropenic patient

• Fever may also occur as a complication of Fever may also occur as a complication of transfusion, drugs, or be a symptom of cancer i.e. transfusion, drugs, or be a symptom of cancer i.e. lymphoma, renal cell carcinomalymphoma, renal cell carcinoma

Definition- Definition- Neutropenic Neutropenic Fever Fever

Neutropenic Fever Neutropenic Fever =Pyrexia in the =Pyrexia in the presence of neutrophil count less than presence of neutrophil count less than 1.0 x 101.0 x 1099/l/l• Patients with neutropenic fever may Patients with neutropenic fever may rapidly develop neutropenic sepsis rapidly develop neutropenic sepsis without prompt appropriate treatmentwithout prompt appropriate treatment

Definition- Definition- Neutropenic Neutropenic SepsisSepsis

Neutropenic Sepsis Neutropenic Sepsis = Hypotension ( systolic = Hypotension ( systolic <100mmg/Hg) and or Tachycardia (pulse >100bpm) <100mmg/Hg) and or Tachycardia (pulse >100bpm) in the presence of a neutrophil count less than 1.0 in the presence of a neutrophil count less than 1.0 x10x1099/l and infection. /l and infection.

• Patients with neutropenic sepsis will Patients with neutropenic sepsis will NOT NOT necessarilynecessarily have a fever have a fever

• Patients with neutropenic sepsis have a Patients with neutropenic sepsis have a HIGH HIGH MORTALITY WITHOUT PROMPT APPROPRIATE MORTALITY WITHOUT PROMPT APPROPRIATE TREATMENTTREATMENT

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

Patients receiving chemotherapy for malignant diseasePatients receiving chemotherapy for malignant disease Particularly between 5 and 28 days after receiving cytotoxic Particularly between 5 and 28 days after receiving cytotoxic

chemotherapychemotherapy

Patients with haematological conditions associated with Patients with haematological conditions associated with neutropenianeutropenia

LeukeamiaLeukeamia LymphomaLymphoma MyelodysplasiaMyelodysplasia

Patient receiving other drugs associated with neutropeniaPatient receiving other drugs associated with neutropeniaPatients with neutropenia due to other causesPatients with neutropenia due to other causes

Chemotherapy and Chemotherapy and neutropenianeutropenia•In patients receiving chemotherapy for solid tumours the white In patients receiving chemotherapy for solid tumours the white count nadir most commonly occurs count nadir most commonly occurs 7-14 days7-14 days after chemotherapy after chemotherapy has been given. In the treatment of solid tumours is usually short has been given. In the treatment of solid tumours is usually short lived and recovers spontaneously within 7 days. However patients lived and recovers spontaneously within 7 days. However patients may be at risk of a febrile neutropenic event at any time throughout may be at risk of a febrile neutropenic event at any time throughout the chemotherapy cycle. the chemotherapy cycle.

•Patients receiving chemotherapy for haematological malignancy i.e. Patients receiving chemotherapy for haematological malignancy i.e. leukaemia or lymphoma may have a deeper and longer lasting leukaemia or lymphoma may have a deeper and longer lasting period of neutropeniaperiod of neutropenia and may be at high risk of developing and may be at high risk of developing neutropenic sepsisneutropenic sepsis

Management of Management of Neutropenic feverNeutropenic fever

Patients at risk of neutropenia presenting to Patients at risk of neutropenia presenting to EAU or A+E with pyrexia should be treated EAU or A+E with pyrexia should be treated as an as an emergencyemergency and should be triaged as and should be triaged as REDRED

These patients include These patients include

•those those within 5 – 28 dayswithin 5 – 28 days after delivery of after delivery of cytotoxic cytotoxic chemotherapychemotherapy

In EAUIn EAU

Do NOT wait for blood testsDo NOT wait for blood tests to confirm neutropenia as to confirm neutropenia as this may waste valuable time.this may waste valuable time.

Treat with intravenous antibiotics immediately Treat with intravenous antibiotics immediately andand

assess for signs of sepsis assess for signs of sepsis i.e.i.e.

HYPOTENSIONHYPOTENSION

TACHYCARDIATACHYCARDIA

If the signs of sepsis are If the signs of sepsis are notnot present the patient should present the patient should be managed on the be managed on the NEUTROPENIC FEVER CARE NEUTROPENIC FEVER CARE PATHWAY.PATHWAY.

Neutropenic care Neutropenic care pathwaypathwayThe Oncology or Heamatology Team on call should The Oncology or Heamatology Team on call should be contacted to inform them of the admission.be contacted to inform them of the admission.

Commence Tazocin and Gentamycin immediately Commence Tazocin and Gentamycin immediately without waiting for results of FBC or cultures without waiting for results of FBC or cultures

If the patient is not neutropenic the antibiotic regime If the patient is not neutropenic the antibiotic regime may be altered latermay be altered later

When possible take blood cultures prior to giving When possible take blood cultures prior to giving antibiotics but do not delay the antibiotic therapyantibiotics but do not delay the antibiotic therapy..

Door to Needle Time < 4 Door to Needle Time < 4 hourshours

Antibiotic therapy should be given Antibiotic therapy should be given WITHIN WITHIN 4 hours4 hours of the patient entering the hospital of the patient entering the hospital

It is the It is the admitting doctor’s responsibilityadmitting doctor’s responsibility to to ensure that intravenous antibiotics are ensure that intravenous antibiotics are given promptly.given promptly.

CARE PATHWAYCARE PATHWAY

COMMENCE ALL PATIENTS WITH COMMENCE ALL PATIENTS WITH NEUTROPENIC FEVER ON THE NEUTROPENIC FEVER ON THE NEUTROPENIC FEVER CARE PATHWAY NEUTROPENIC FEVER CARE PATHWAY FOR THE FIRST 48 HOURS OF FOR THE FIRST 48 HOURS OF ADMISSION.ADMISSION.

FOLLOW MANAGEMENT AS DICTATED BY FOLLOW MANAGEMENT AS DICTATED BY THE CAREPATHWAYTHE CAREPATHWAY

HistoryHistory

Symptoms to point to source of infectionSymptoms to point to source of infection Eg. Cough, dysuria, hickman line, skin, mouth, ENT, GU Eg. Cough, dysuria, hickman line, skin, mouth, ENT, GU

symptoms, diarrhoea,symptoms, diarrhoea,

Co-morbid diseaseCo-morbid disease Treatment historyTreatment history

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

Drug historyDrug history Antibiotics, drugs known to cause neutropenia, number of Antibiotics, drugs known to cause neutropenia, number of

days since chemotherapydays since chemotherapy

ExaminationExamination

Signs of infection?Signs of infection? Respiratory,Respiratory, Hickman line site,Hickman line site, Skin,Skin, Abdominal,Abdominal, CNS, CNS, oral cavityoral cavity

Do not perform a PRDo not perform a PR This may cause addition sepsis in the This may cause addition sepsis in the

neutropenic patientneutropenic patient

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

Gram negative sepsis occurs from patients Gram negative sepsis occurs from patients own bowel floraown bowel flora

Investigations on Investigations on admissionadmission

Blood culturesBlood cultures If the patient has a hickman or PICC line take cultures from If the patient has a hickman or PICC line take cultures from

both line and peripherally (direct from vein).both line and peripherally (direct from vein). U+EU+E

Septic patients may develop renal failureSeptic patients may develop renal failure Gentamycin is renally toxicGentamycin is renally toxic

CRPCRP MSUMSU FBCFBC Blood gases if septic or hypoxicBlood gases if septic or hypoxic CXRCXR

G-CSFG-CSF

G-CSF ( granulocyte colony stimulating G-CSF ( granulocyte colony stimulating factor) has factor) has no roleno role in the acute in the acute management of uncomplicated management of uncomplicated neutropenic feverneutropenic fever

G-CSF is a consultant only prescription G-CSF is a consultant only prescription drug at New Cross Hospitaldrug at New Cross Hospital

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

This IncludesThis Includes Patients with Patients with haematological malignancyhaematological malignancy

Leukeamia, Lymphoma, myeloma,Leukeamia, Lymphoma, myeloma, Patients with Patients with uncontrolled solid tumoursuncontrolled solid tumours

Cancer symptoms,Cancer symptoms, Patients receiving Patients receiving chemotherapy with palliative intentchemotherapy with palliative intent Patients with significant concomitant medical conditionsPatients with significant concomitant medical conditions

i.e. CCF, COADi.e. CCF, COAD Patients aged Patients aged over 65over 65 Patients already on antibioticsPatients already on antibiotics Patients with an identifiable infective focusPatients with an identifiable infective focus

e.g. LRTI, UTIe.g. LRTI, UTI

Management of High Risk Management of High Risk Patients on AdmissionPatients on Admission

High risk patients requireHigh risk patients require IV fluidsIV fluids Regular pulse and BPRegular pulse and BP Regular medical reviewRegular medical review Specialist Oncology/Heamatology review within Specialist Oncology/Heamatology review within

24 hours of admission24 hours of admission..

In addition to prompt antibiotic therapy.In addition to prompt antibiotic therapy.

High Risk or Low Risk of High Risk or Low Risk of Developing Neutropenic Developing Neutropenic sepsis?sepsis?

When in doubt ALWAYS assume the patient When in doubt ALWAYS assume the patient is at HIGH risk of neutropenic sepsisis at HIGH risk of neutropenic sepsis

The oncology team will determine the risk The oncology team will determine the risk category and commence patients on the low category and commence patients on the low risk pathway if appropriate.risk pathway if appropriate.

Next dayNext day

Examine patientExamine patient cardiovascular stabilitycardiovascular stability

Gentamycin levelsGentamycin levels Check FBCCheck FBC Check U+EsCheck U+Es Review fluid requirementsReview fluid requirements Contact oncology/heamatology team if Contact oncology/heamatology team if

this has not already been done.this has not already been done.

NEUTROPENIC SEPSISNEUTROPENIC SEPSIS

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

Management of these patients is Management of these patients is individualised according to needindividualised according to need

MANAGEMENT IF MANAGEMENT IF NEUTROPENIC SEPSISNEUTROPENIC SEPSIS

ALL PATIENTS REQUIRE ALL PATIENTS REQUIRE IMMEDIATE ANTIBIOTIC IMMEDIATE ANTIBIOTIC THERAPYTHERAPY

ALL PATIENTS REQUIRE ALL PATIENTS REQUIRE IMMEDIATE AND IMMEDIATE AND AGGRESSIVE FLUID RESUSSITATIONAGGRESSIVE FLUID RESUSSITATION

IF THE PATIENT FAILS TO RESPOND TO INITIAL IF THE PATIENT FAILS TO RESPOND TO INITIAL FLUID RESUSITATON FLUID RESUSITATON HDU/ITUHDU/ITU ADMISSION MUST ADMISSION MUST BE CONSIDEREDBE CONSIDERED

REGULAR OBSERVATIONS ARE MANATORY, REGULAR OBSERVATIONS ARE MANATORY, IMMEDIATE ACTION IS REQUIRED IN THE EVENT IMMEDIATE ACTION IS REQUIRED IN THE EVENT OF CARDIOVASCULAR INSTABILITYOF CARDIOVASCULAR INSTABILITY

THE ONCOLOGY/HEAMATOLOGY TEAM MUST BE THE ONCOLOGY/HEAMATOLOGY TEAM MUST BE INFORMED INFORMED

Where can I get help?Where can I get help?

The oncologist or heamatologist on-call is available The oncologist or heamatologist on-call is available though switch-board. though switch-board. 24hr advice is available24hr advice is available.. Dial 0 and ask to speak to the on-call oncologist or Dial 0 and ask to speak to the on-call oncologist or

heamatologistheamatologist The neutropenic care pathway document ( hard copy) The neutropenic care pathway document ( hard copy)

is available in EAU, CHU, Deanesly ward and Durnall is available in EAU, CHU, Deanesly ward and Durnall suite. It is also available to print off directly from the suite. It is also available to print off directly from the IntranetIntranet

Advice on neutropenic fever, neutropenic sepsis and Advice on neutropenic fever, neutropenic sepsis and other oncological emergencies are available on the other oncological emergencies are available on the intranet. intranet.