Fever + low neutrophils = panic
- Patients have (usually) had chemotherapy within past 7-14 days → important to elucidate this information on history.
- Start tazocin + gentamicin in all patients with ?febrile neutropaenia w/i 1 hour of presentation (ASAP) after obtaining blood cultures.
- If patient has been given GCSF, it can mask neutropaenia. Similarly, paracetamol can mask fever.
- Never perform a DRE in a ?FN patient.
- Giving GCSF in acute setting doesn’t improve mortality but can ↓ duration of hospital stay and ↓ duration of neutropaenia.
- Febrile = temperature > 38.3 ℃ (single occasion) OR temperature > 38 ℃ (2 occasions, 1 hour apart).
- Neutropaenia = absolute neutrophilic count (ANC) < 1.5 cells/litre
- Note: severe neutropaenia if ANC < 0.5 cells/litre or predicted to drop below this in next 2 hours
If patient reports a subjective fever at home but there are no recorded fevers in healthcare setting, still proceed through management pathway.
- TRIAGE 2 MEDICAL EMERGENCY (same as stroke or chest pain)
- Source of infection identified in only 20-40% of cases
Common sources include:
- Gastrointestinal, genitourinary, lines (e.g. PICC lines, Portacath), skin, oral ulcers, respiratory tract
Common bacteria include:
- Pseudomonas, Staphyloccoccus, Streptococcus, E. coli, Klebsiella
- Atypical bacteria e.g. mycoplasma, legionella
- Collection (abscess) e.g. intra-abdominal, spinal
- Cardiac vegetations → echo
- Affects patients 7-14 days post-chemotherapy (this is the nadir i.e. the lowest point of the neutrophil count)
- Not all chemotherapeutics are equal. Some (e.g. alkylating agents, taxanes) are more likely to kill bone marrow and cause neutropaenia.
- Recent chemo
- Non-specific symptoms e.g. lethargy, malaise
- Infective symptoms (respiratory, urinary, GI, cutaneous, intracranial, oral)
- Vascular devices in-situ
GCSF given post-chemo:
- Usually given 24h post-chemo in chemotherapy regimens with ↑ likelihood of causing neutropaenia
- Can mask neutropaenia
- Pegfilgrastim = long-acting GCSF; filgrastim = short-acting GCSF
Pus may not be present as neutrophils are what’re responsible for pus generation.
- Source - skin, oral mucosa, vascular devices ENT, eye, further systematic examination
Never perform DRE in ?FN as it may → ↑ bleeding or can promote bacterial shower into bloodstream.
Initiate septic pathway.
- ≥ 2 sets of blood cultures at separate sites (or one from vascular device and one elsewhere) BEFORE Abx
- FBC, UEC, CMP, LFT, coags, lactate, procalcitonin, CRP
- Urine MCS, stool culture
- Sometimes: skin swab, echo, MRI spine
Start Abx within 1 hour of presentation to reduce mortality rates.
- In HNELHD:
- w/o penicillin allergy → tazocin (piperacillin + tazobactam) 4.5g IV + gentamicin 5-7 mg/kg IV
- w/ mild penicillin allergy → ceftazidime + gentamicin
- w/ severe penicillin allergy (anaphylaxis) → meropenem + gentamicin
- In any of the above, consider adding vancomycin if suspected line sepsis (i.e. the source is an indwelling line e.g. PICC line, Portacath)
- Note: check eTG or HealthPathways prior to prescribing antibiotics until you feel comfortable with the specific medications
- Fluid resuscitation.
- Target Abx after culture results return.
Don’t chart regular paracetamol (can mask fever) just use PRN.
- If fever persists > 24h → repeat septic screen (look for source)
- If fever persists > 48-72h → broaden Abx coverage and repeat septic screen (include imaging to detect abscesses)
- If fever persists > 72h, consider discussion with Infectious Diseases.