Neutropenic Sepsis Flashcards
(24 cards)
when is neutropenia seen in chemotherapy
around day 7-14 of each 3-weekly cycle
- BUT can be seen up to 6 weeks post chemo
what is a normal neutrophil count
> 1.5x10(9)
when is an increased risk of infection noted
when neutrophils <1.0x10(9)
markedly increased at <0.5x10(9)
what are symptoms of infections in neutropenic patients
feeling hot/feverish/cold/shivery
aching joints/muscles
flu like symptoms
focal infection - cough, sore throat, UTI, etc
at what temperatures should patents seek medical assessment
one recording of >38.5 or <36
OR
two recording of >38.8 two hrs apart
when can neutropenic fever be diagnosed
- patient is febrile
- neutrophil count <1.0x10(9)
- no haem-dynamic compromise
when can neutropenic sepsis be diagnosed
evidence of sepsis (eg hypotension, tachycardia)
AND
neutrophil count <1.0x10(9) (+/- fever)
pathogenic causes of neutropenic sepsis (ie microbiology)
85% - endogenous flora (eg from gut, biliary, urinary tracts)
75% cases gram -ve bacilli
fungal in prolonged neutropenia (esp in haem malignancies)
non-specific symptoms
anorexia
malaise
lethargy
sweats
specific symptoms of infection
fever, chills, riggers
symptoms related to a focus of infection
what should you ask in a systematic enquiry
Chest infection (eg cough) GI tract (eg diarrhoea) Urinary tract (eg dysuria) CNS (eg headache) Skin infections/abscesses sore throat recent interventions (eg dental)
key examinations
temp pulse BP O2 sats resp rate full exams of each system for infection source
Investigations - bloods
FBC UE Liver function CRP Coagulation screen (DIC) blood cultures
Investigations - other
Bone profile MSSU stool culture (diarrhoea) throat swab ([haryngitis) sputum culture skin swabs CXR
other guided by clinical status - eg LP, CT, etc
Management
supportive care - volume resus (colloid/crystalloid)
O2 therapy
mouth care
broad spectrum AB
G-CSP (granulocyte colony stimulating factor) to boost neutrophil count
What antibiotics are used for NS - stage 1
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
Monitoring
temp pulse BP O2 sats UO - catheter if hypotensive check cultures to optimise AB FBC, UE, CRP daily
why might you transfer a NS patient to ITU
if hypotension does not resolve with supportive measures at ward level
what are the stage 2 AB
meropenem 1g IV every 8 hours (unless cultures suggest otherwise)
when should you switch from stage 1 to stage 2 AB
if patient is still febrile 48hrs after stage 1, or if patient is repaid deteriorating despite stage 1 AB
how do you review fluid requirements
assess fluid intak/output
vital signs
clinical evidence of underselling/overfilling
UE
how do you review response to AB therapy
temp
BP pulse
CRP
Neutrophil count
How long should a NS patient be on an antibiotic course
minimun 3 days IV
when can patients come off IV AB
if after a minimum of 3 days on IV they are improving and are no longer neutropenic - can switch to oral ciprofloxacin