Canterbury DHB

Context

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:

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.

Stages of empirical antimicrobial therapy

Stage

Action

1

  • First line: Piperacillin/tazobactam (Tazocin®) and a single dose of gentamicin*. Gentamicin levels are not required for single doses. If blood cultures indicate Pseudomonas or other difficult-to-treat enterobacteriaceae, continue to treat with an aminoglycoside, take levels, and dose adjust according to levels. Consider the use of tobramycin instead of gentamicin in this setting, depending on sensitivities. Flucloxacillin or vancomycin should be added if staphylococcal sepsis is suspected.
  • For patients with severe penicillin allergy (e.g. anaphylaxis) consider ciprofloxacin 400 mg BD IV and vancomycin in standard treatment doses (see below).
  • Second line: Meropenem. (Imipenem can also be used but is no longer cheaper than meropenem).
  • Third line: Cefepime.

Refer to doses under specific drug subheadings.

* Aminoglycosides should not be used for patients receiving high dose methotrexate.

2

  • If fever does not settle, consider discussing with ID team and adding:

    or

    • Metronidazole 400 mg TDS orally, especially if the patient has diarrhoea or abdominal symptoms.

3

  • If fever has not settled, consider empirical antifungal therapy with Voriconazole. See fungal section below.

About this Canterbury DHB document (9476):

Document Owner:

Ruth Spearing and Sarah Metcalfe (see Who's Who)

Issue Date:

November 2016

Next Review:

November 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 9476