Fever in a Neutropenic Patient

Fever in a Neutropenic Patient

·        Eg in patients undergoing chemotherapy

·        Indicators of serious infection:

o  Signs and symptoms of infection will be reduced – can‟t mount an inflammatory response

o  Temperature:

§  > 38.5 C

§  > 38 for 4 hours

§  Patient fells unwell but no temperature

o  Neutropenia: 

§  Neutrophils < 0.5 * 10E9/L (less than 0.2 Þ serious concern)

§  Neutrophils falling

§  Prolonged neutropenia (> 7 days)

·        Types of infection (drives focused history)

o  Respiratory: SOB, cough

o  Skin infection

o  Mouth and teeth

o  Perianal (pain on moving bowels and wiping)

o  Pain around central line

o  Less often: bowel & UTI

·        Focused exam:

o  Signs of septic shock: Pulse, BP and peripheral circulation

o  Chest: percussion and auscultation

o  Mouth: a good look around – abscesses will be sensitive to pain

o  Skin infections, especially lines

o  Quick abdominal 

o  Exam perianal area – test for sensitivity to touch. Don‟t do PR (risk of minor trauma ® bacteraemia) 

·        Investigations:

o  FBC

o  Blood culture (debate about whether to take it from the central line or not)

o  CXR

o  Swabs from anything that looks infected, including central line 

o  Maybe CRP: ­ in bacteraemia

·        Normally don‟t find anything.  Over half infections are low grade line infections

·        If in doubt, treat empirically now.  If infected will deteriorate quickly:

o  Gentamycin + Ticarcillin (synthetic penicillin)

o  Monotherapy (eg imipenem)

o  +/- Vancomycin (for staph line sepsis)

·        Causes of infection:

·        Subsequent fevers: longer in hospital (­hospital acquired infection), longer on antibiotics, etc

·        If fever persists:

o   Repeat the above exam and investigations – but unlikely to add anything new

o   Choices:

§  Change antibiotics

§  Consider antifungal: Amphotericin.  Watch for nephrotoxicity and the patient feels awful

·        Obscure fevers:

o   Central venous line infection

o   Occult sinusitis (check with CT) 

o   Hepatosplenic candidiasis (check with CT ® abscess ® biopsy)

o   Pulmonary/disseminated aspergillus (doesn‟t respond to amphotericin)

o   Viral

o   Drugs

·        Prevention:

o   Avoid hospitalisation

o   Strict hand washing

o   Avoid invasive procedures (beware interventionist surgeons!)

o   Care of IV devices

o   Consider prophylactic antimicrobials

·        Prophylaxis 

o   Bacteria: selective gut decontamination (origin of many infections is bowel flora): Ciprofloxacin (fluorinated quinolone). Arguments for and against 

o   Anti-fungal: Fluconazole, Itraconazole (OK for prophylaxis, not so good as amphotericin for established infection) 

o   Anti-viral: acyclovir (for HSV), ganciclovir (for CMV)

o   Anti-pneumocystis: co-trimoxazole (but beware marrow suppression) or aerolised pentamidine

·        Other possible treatments: 

o   Granulocyte-CSF: try to ­ marrow production of neutrophils

o   Maybe g-globulin infusions

o   Transfuse granulocytes: emerging area