DEFINED as temperature > 38ºC and absolute neutrophil count < 0.5 × 109/L or <1.0 x 109/L and falling rapidly
although a subgroup of low-risk neutropenic patients may be able to be managed (at home) with oral therapy, most will need to be admitted for urgent empirical IV antibiotics regardless of their clinical appearance, as infections may become fulminant within hours, & clinical manifestations are frequently modified.
NOTE THAT patients on cytotoxic chemotherapy within past 2 weeks with T >= 38degC on two occasions > 1hr apart or >= 38.3degC OR temperature below 36 degC (possible “cold sepsis”) should be managed as per febrile neutrepenia
initial Mx
febrile chemotherapy patients should be triaged as triage 2 and iv antibiotics should be commenced within 30 minutes of arrival in ED
initiation of IV antibiotics should not be delayed waiting for confirmation of neutropenia on FBE
only medical and nursing staff who are credentialed in care of Portacaths and PICC lines are able to take blood cultures via these devices
iv or central line access
FBE, U&E, LFT, Ca, PO4, and other investigations as indicated
coagulation profile if on warfarin
glucose if diabetic
2 sets of blood cultures if possible (if PICC line or Portacath in situ one set should be taken from this by a credentialled staff member, otherwise take from peripheral sites)
early discussion with Infectious Diseases team
early commencement of empirical antibiotics
further septic workup:
CXR
MSU m/c/s
stool culture if diarrhoea (including C. difficile toxin and culture).
sputum m/c/s
empirical antibiotics
patients WITHOUT immediate hypersensitivity to penicillins
piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8-hourly, OR,
cefepime 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly (if mild penicillin allergy)
add gentamicin if systemically compromised (BP ≤90/60mmHg)
is known to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
has clinical evidence of a catheter-related infection in a unit with a high incidence of MRSA infection
poor response to Rx by 48hrs of therapy and a Gram-positive organism resistant to other drugs is isolated from blood culture or if the patient has progression of a clinical infection
consider adding antifungals if
fevers persist in high-risk patients beyond 96 hours of antibacterial therapy
patients WITH severe immediate hypersensitivity to penicillins
discuss with Infectious Diseases specialist
consider:
Ciprofloxacin 400 mg bd plus,
Vancomycin, plus,
stat dose Gentamicin 5-7mg/Kg if systemically compromised (BP ≤90/60mmHg)