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Management of Neutropenic Sepsis in Adults Pathway

Symptoms

Fever of 38.3°C or more on one occasion, or 38.0°C or more sustained for 1 hour in a patient at risk of neutropenia e.g. post chemotherapy, but the possibility of sepsis must be considered in any unwell patient irrespective of temperature e.g. chills, rigors, unexplained hypotension or hypoxia, signs or symptoms of chest infection.

History & exam with particular attention to the following:

  • Nature of chemotherapy, days since completed
  • History of bone marrow or stem cell transplant
  • Drug allergies
  • Evidence of infection
  • Oropharynx, sinuses, perineum, central venous lines, skin lesions, chest, abdomen
  • Evidence of septicaemic shock, hypoxia, renal failure, DIC

 

Investigations

  • Two sets of blood cultures including set from any central venous lines
  • Culture symptomatic sites e.g. throat and skin swabs, sputum, MSU, stool
  • Radiology of symptomatic areas e.g. chest X-ray
  • If not already done that day - check FBC, U&Es, LFTs, CRP, G&S +/- coag screen is? DIC?
  • Check Serum Lactrate (arterial or venous)
  • NEVER WAIT FOR RESULTS BEFORE STARTING IV ANTIBIOTICS

Discuss all cases with the on-call consultant microbiologist

Commence first line antibiotic therapy without delay prescribing first dose on the once-only part of the chart - piperacillin-tazobactam(Tazocin) 4.5g tds, gentamicin 5mg/kg od (max. 500mg)

OMIT Gentamicin to Oncology patients unless authorised by Oncologist

If there has been anaphylaxis with penicillins discuss with on call microbiology. If there is a history of only rash with penicillin give meropenem 1q tds.

Antibiotics must be given as soon as possible and definitely within one hour of the hospital admission.

Consider need for additional therapy

  • If septicaemic shock and/or hypoxia _ IV fluid, O2 + GCSF (Granocyte 263mcg sc od)
  • Consider ITU referral if patient unstable or fails to improve on the above - discuss with consultant
  • Cellulitis at iv catheter sites - teicoplanin
  • Severe oral GIT mucositis - teicoplanin
  • Herpetic lesions - acyclovir