Neutropenic Fever

1. New Cross Hospital Induction NeutropenicFever

2. 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/mm3will 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

3. Definition of Pyrexia • Oral or tympanic membrane temperature of >38C • Note fever may not be present in patients who are dehydrated, on steroids or NSAIDs and the possibility of infection must be considered in any unwell neutropenic patient • Fever may also occur as a complication of transfusion, drugs, or be a symptom of cancer i.e. lymphoma, renal cell carcinoma

4. Definition- Neutropenic Fever Neutropenic Fever =Pyrexia in the presence of neutrophil count less than 1.0 x 109/l Patients with neutropenic fever may rapidly develop neutropenic sepsis without prompt appropriate treatment

5. Definition- Neutropenic Sepsis Neutropenic Sepsis = Hypotension ( systolic <100mmg/Hg) and or Tachycardia (pulse >100bpm) in the presence of a neutrophil count less than 1.0 x109/l and infection. Patients with neutropenic sepsis will NOT necessarily have a fever Patients with neutropenic sepsis have a HIGH MORTALITY WITHOUT PROMPT APPROPRIATE TREATMENT

6. Patients at risk of neutropenic fever and sepsis Patients receiving chemotherapy for malignant disease Particularly between 5 and 28 days after receiving cytotoxic chemotherapy Patients with haematological conditions associated with neutropenia Leukeamia Lymphoma Myelodysplasia Patient receiving other drugs associated with neutropenia Patients with neutropenia due to other causes

7. Chemotherapy and neutropenia In patients receiving chemotherapy for solid tumours the white count nadir most commonly occurs 7-14 days after chemotherapy has been given. In the treatment of solid tumours is usually short lived and recovers spontaneously within 7 days. However patients may be at risk of a febrile neutropenic event at any time throughout the chemotherapy cycle. Patients receiving chemotherapy for haematological malignancy i.e. leukaemia or lymphoma may have a deeper and longer lasting period of neutropenia and may be at high risk of developing neutropenic sepsis

8. Management of Neutropenic fever Patients at risk of neutropenia presenting to EAU or A+E with pyrexia should be treated as an emergency and should be triaged as RED These patients include those within 5 – 28 days after delivery of cytotoxic chemotherapy

9. In EAU Do NOT wait for blood tests to confirm neutropenia as this may waste valuable time. Treat with intravenous antibiotics immediately and assess for signs of sepsis i.e. HYPOTENSION TACHYCARDIA If the signs of sepsis are not present the patient should be managed on the NEUTROPENIC FEVER CARE PATHWAY.

10. Neutropenic care pathway The Oncology or Heamatology Team on call should be contacted to inform them of the admission. Commence Tazocin and Gentamycin immediately without waiting for results of FBC or cultures If the patient is not neutropenic the antibiotic regime may be altered later When possible take blood cultures prior to giving antibiotics but do not delay the antibiotic therapy .

11. Door to Needle Time < 4 hours Antibiotic therapy should be given WITHIN 4 hours of the patient entering the hospital It is the admitting doctor’s responsibility to ensure that intravenous antibiotics are given promptly.

12. CARE PATHWAY COMMENCE ALL PATIENTS WITH NEUTROPENIC FEVER ON THE NEUTROPENIC FEVER CARE PATHWAY FOR THE FIRST 48 HOURS OF ADMISSION. FOLLOW MANAGEMENT AS DICTATED BY THE CAREPATHWAY

13. History Symptoms to point to source of infection Eg. Cough, dysuria, hickman line, skin, mouth, ENT, GU symptoms, diarrhoea, Co-morbid disease Treatment history Cancer diagnosis, stage, prior treatment, date of last treatment Drug history Antibiotics, drugs known to cause neutropenia, number of days since chemotherapy

14. Examination Signs of infection? Respiratory, Hickman line site, Skin, Abdominal, CNS, oral cavity Do not perform a PR This may cause addition sepsis in the neutropenic patient

15. IN MOST PATIENTS A SCOURCE OF INFECTION IS NOT FOUND but does not exclude an infective diagnosis • Gram negative sepsis occurs from patients own bowel flora

16. Investigations on admission Blood cultures If the patient has a hickman or PICC line take cultures from both line and peripherally (direct from vein). U+E Septic patients may develop renal failure Gentamycin is renally toxic CRP MSU FBC Blood gases if septic or hypoxic CXR

17. G-CSF G-CSF ( granulocyte colony stimulating factor) has no role in the acute management of uncomplicated neutropenic fever G-CSF is a consultant only prescription drug at New Cross Hospital

18. High risk patients are at risk of progressing from neutropenic fever to sepsis This Includes Patients with haematological malignancy Leukeamia, Lymphoma, myeloma, Patients with uncontrolled solid tumours Cancer symptoms, Patients receiving chemotherapy with palliative intent Patients with significant concomitant medical conditions i.e. CCF, COAD Patients aged over 65 Patients already on antibiotics Patients with an identifiable infective focus e.g. LRTI, UTI

19. Management of High Risk Patients on Admission High risk patients require IV fluids Regular pulse and BP Regular medical review Specialist Oncology/Heamatology review within 24 hours of admission. In addition to prompt antibiotic therapy.

20. High Risk or Low Risk of Developing Neutropenic sepsis? When in doubt ALWAYS assume the patient is at HIGH risk of neutropenic sepsis The oncology team will determine the risk category and commence patients on the low risk pathway if appropriate.

21. Next day Examine patient cardiovascular stability Gentamycin levels Check FBC Check U+Es Review fluid requirements Contact oncology/heamatology team if this has not already been done.

22. NEUTROPENIC SEPSIS Patients with neutropenia plus tachycardia or hypotension are at high risk of death Management of these patients is individualised according to need

23. MANAGEMENT IF NEUTROPENIC SEPSIS ALL PATIENTS REQUIRE IMMEDIATE ANTIBIOTIC THERAPY ALL PATIENTS REQUIRE IMMEDIATE AND AGGRESSIVE FLUID RESUSSITATION IF THE PATIENT FAILS TO RESPOND TO INITIAL FLUID RESUSITATON HDU/ITU ADMISSION MUST BE CONSIDERED REGULAR OBSERVATIONS ARE MANATORY, IMMEDIATE ACTION IS REQUIRED IN THE EVENT OF CARDIOVASCULAR INSTABILITY THE ONCOLOGY/HEAMATOLOGY TEAM MUST BE INFORMED

24. Where can I get help? The oncologist or heamatologist on-call is available though switch-board. 24hr advice is available. Dial 0 and ask to speak to the on-call oncologist or heamatologist The neutropenic care pathway document ( hard copy) is available in EAU, CHU, Deanesly ward and Durnall suite. It is also available to print off directly from the Intranet Advice on neutropenic fever, neutropenic sepsis and other oncological emergencies are available on the intranet.