Canterbury DHB

Management of the Septic Immunosuppressed Patient

See the Emergency Department Immunosuppressed Patients Clinical Pathway (C240085).

Sepsis in a significantly immunosuppressed (and especially in a neutropenic) patient can be a medical emergency. The only sign present may be fever. However, equally, the patient may be afebrile and the evidence for the infection may be a rising CRP or rigors. We have had a number of patients where a significant rise in CRP was associated with positive blood cultures despite the temperature not being raised. Shivers or rigors, abdominal tenderness or other signs of inflammation, are also an indication to undertake cultures and commence antibiotics – we have had many examples of patients with septicaemias who are not actually febrile. The septic neutropenic patient requires immediate IV antibiotics. There may be exceptions to this statement, but this is a consultant decision.

Although patients may have septicaemias and other infections without any fevers, all immunosuppressed patients with a temperature of 38 degrees or higher should be commenced on antibiotics – unless there has been a consultant decision that the fever is due to a non-infective cause. All intensively-treated haematology patients with neutrophil counts of <0.5 x10⁹/L should have broad spectrum antibiotics written up so the nurses can commence taking the cultures.

Before antibiotics are started, a set of blood cultures from each lumen of the central catheter should be taken, along with:

• a set of peripheral cultures
• an MSU
• a swab of any inflamed areas
• sputum if present

Ensure adequate hydration.

Note: If the patient doesn't have a central line, at least two sets of peripheral cultures must be taken. Indicate clearly which blood cultures are central or peripheral.

If changing antibiotics, take blood cultures beforehand (central only is sufficient if line present) and repeat (e.g. every 48-72 hours) if the if the temperature isn’t trending down.

Fever is usually defined as a temperature above 38°C.

Antimicrobial therapy in immunocompromised patients

See the Sepsis section and the May 2022 bulletin in the CDHB Pink Book.

Topic Code: 9476