Transcript Neutropaenic Sepsis01

Neutropaenic Sepsis
Based on the 2002 IDSA Guidelines for
Use of Antimicrobial Agents in
Neutropaenic Patients with Cancer
Definitions
Fever
Single oral temperature >/= 38.3oC
Neutropaenia
Neutrophil count < 500 cells/mm3
At least 50% of neutropaenic patients
who become febrile have an
established or occult infection.
At least 20% of patients with neutrophil
counts <100 cells/mm3 have
bacteraemia
Common sites of Infection
Eye
Periodontium
Pharynx/ Lwr
Oesophagus
Lungs
BMA sites
Perineum/ Anus
Vascular Catheter/
Tissue around nails
Symptoms and Signs of Inflammation
may be absent!
No induration/erythema
No cellulitis
No CXR changes
No pyuria
No pleocytosis in CSF
Investigations
Full Blood Count and
Urea/Electrolytes/Creatinine
Chest X-ray
Urine Culture/Microscopy
Lumbar Puncture
Blood Cultures
Biopsy/Aspiration of Skin lesions
FBC & U/E/Cr
For:
 monitoring drug toxicity*
 planning supportive care
Every 3 days during antibiotic treatment
(*Esp. for nephrotoxic drugs like amphoterecin B, cisplatin,
cyclosporine, vancomycin, gentamycin etc.)
Back to Investigations
CXR
For patients
with signs and symptoms of a respiratory tract
abnormality
managed as outpatients
Not cost-effective on a routine basis
Back to Investigations
Urine Culture/Microscopy
For patients who have:
signs and symptoms of a urinary tract infection
urinary catheter in place
Little use as a routine investigation
Back to Investigations
Lumbar Puncture
For patients with:
suspected CNS infection
No/manageable thrombocytopaenia
Not recommended as a routine procedure
Back to Investigations
Blood Cultures
>/= 1 set of blood cultures from catheter
lumen + from peripheral vein
Allows for comparison when catheterrelated infection is suspected
Any fluid from an inflamed/draining
catheter site should be Gramstained/cultured for bacteria/fungi/non-TB
mycobacterium
Back to Investigations
Biopsy/Aspiration of Skin Lesions
For skin lesions that appear infected
Send for cytology, Gram staining and
culture
Investigations
Full Blood Count and
Urea/Electrolytes/Creatinine
Chest X-ray
Urine Culture/Microscopy
Lumbar Puncture
Blood Cultures
Biopsy/Aspiration of Skin lesions
All neutropaenic patients with
fever or with signs and symptoms
compatible with an infection
require prompt empirical antibiotic
therapy
Microbiology
 Gram + (60%)
S. aureus*
S. epidermidis*
S. pneumoniae*
S. pyogenes*
Viridans Strep*
Enterococcus*
Corynebacteria*
Listeria monocytogenes
 Gram –
E. coli*
Klebsiella*
P. aeruginosa*
Enterobacter
Proteus
H. influenzae
 Anaerobes
Bacteroides
Clostridium
Vascular Access Devices
 May be left in place even in catheter-related
infections
 Remove if:
Infection is recurrent
Not responsive to antibiotics after 2-3 days
Tunnel infection established
Bacillus, P. aeruginosa, VRE, C. jeikeium, Acinetobacter,
Candida responsible
 May require debridement for atypical
mycobacterium
“…no single empirical therapeutic
regimen…can be recommended…many
antibiotic regimens are effective in the
control of infection with minimal
toxicity…selection(should be) based on
local patterns of infection and antibiotic
susceptibilities”
ISDA 2002 Guidelines
Starting Antibiotic Therapy – 3 Questions
1. Is the patient a LOW risk or a HIGH risk
patient?
2. For HIGH risk patients, to start with 1
antibiotic or 2 antibiotics?
3. To add vancomycin?
Low Risk >/= 21
Extent of illness
No symptoms
Mild symptoms
Moderate symptoms
No hypotension
No COPD
Solid tumour/no fungal infection
No dehydration
Outpatient at onset of fever
Age < 60
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Other “LOW RISK” factors
 Absolute neutrophil count >/= 100
 Absolute monocyte count >/= 100
 Normal CXR, LFT, U/E/Cr
 Duration of neutropaenia < 7 days
 Expected resolution < 10 days
 Evidence of bone marrow recovery
 Malignancy in remission
 Peak temperature < 39.0oC
 No IV site infection
 Patient is well, no neurological changes, no
abdominal pain, no complications
Oral Antibiotics & Outpatient Management
For LOW RISK patients who have:
no focus of bacterial infection
no symptoms and signs suggestive of systemic
infection
Outcome similar when treated with IV
antibiotics in hospital
Reduced costs, convenience, no IV
devices required, outpatient setting
Ciprofloxacin + Amoxycillin + Clavulanate
Back
Monotherapy
3rd or 4th generation Cephalosporin or
Carapenem
Egs. Ceftazidime, Cefepime, Imipenem,
Meropenem
Many studies show patients have better
response to meropenem compared to
ceftazidime
Quinolones and aminoglycosides not
recommended
Precautions for Monotherapy
Monitor for:
Non-responsiveness
Emergence of secondary infections
Drug-resistance
Adverse effects
Not active against: coag- Staph, VRE,
MRSA, some strains of S. pneumoniae
Back
Two-drug Therapy
Aminoglycoside + antipseudomonal
penicillin
Aminoglycoside + Cefepime
Aminoglycoside + Ceftazidime
Aminoglycoside + Carbapenem
 Advantages:
Synergistic effect against G- rods
Minimal emergence of Drug-Resistant strains
 Disadvantages:
Inactive against some G+ bacteria
Nephrotoicity
Ototoxicity
Hypokalaemia
Back
Vancomycin or not?
Indications:
Suspected serious catheter-related infections
Known colonisation with penicillin- and
cephalosporin- resistant pneumococci or MRSA
Blood culture positive for Gram +
Hypotension or cardiovascular impairment
Intensive chemoRx causing substantial
mucosal damage*
Afebrile neutropaenic patients on quinolone
prophylais before onset of fever*
Recommended Regimens
Vancomycin + Cefepime
Vancomycin + Ceftazidime
Vancomycin + Carbapenem
Aminoglycosides can also be added as a 3rd drug.
The roles of Linezolid, Quinupristine-dalfopristine
and Teicoplanin are still undetermined.