Febrile neutropenia

Definition: neutrophil count less than 0.5x 10^9/L or >38 degrees fever associated with neutrophils less than 1x 10^9/L with predicted to further drop.

DDX:

1. Drugs- post chemo(typically 10-14 days after chemotherapy), cytotoxic agents, carbimazole,sulfonamides.
2. Infection- viral or severe sepsis
3. Autoimmine- neutrophil antibodies (SLE, haemolytic anemia.)
4. hypersplenism - leukemias, felty's syndrome
5. bone marrow failure - Myeloproliferative, mylelofibrosis, malignant infiltration(myeloma), aplastic anemia, leukemia, infection(TB), drugs.
   

Examination: Paying attention to respiratory, abdominal (neutropenia colitis [typhlitits]), cardiac, pelvic(urinary). Look at mouth for mucositis and skin for rashes.

Treatment:

1. Initiated even if patient is afebrile but appears toxic. Assume septicemia.
2. Choice depends on local susceptibility. Cover for pseudomonas due to high morbidity and mortality.
3. Treat with broad spectrum Antibiotics - ceftazidime/cefepine( 4th generation - good pseudomonas cover + gram -ve), + timentin(ticarcillin+calvulanate acid)[ for gram +ve plus pseudomonas cover]. Austin protocol is ceftapine + gentamycin for more sick people and ceftriaxone + stat gentamycin for not so sick people. Note this this does not provide cover for staph aures, enterococci, TB, PCP, anaerobes.
4. Consider vancomycin for hospital acquired MRSA (rising due to increase presence of venous lines), serious shock, intravascular devices(PICC LINES ESPICALLY IN ONCOLOGY PATIENTS). This could result in the death of gut commensals and overpopulation of gut VRE which could lead to sepsis.
5. Treat routinely with anti-fungals(nilstat drop) and mouth washes to control ulcers and fungal mouth infections. Anti-virals if reactivation of VZV or HSV.
6. Consider barrier nursing and postive pressure room.
7. septic work up - blood (3 sets), sputum, urine, stool cultures. Swab also from any peripheral or central line. CXR
8. FBC, U&E, LFT, ABG ( decide if person is in hypoxic drive or not)
9. Continue until afebrile or neutrophil count recovers.
10. Failure to respond after 96 hrs consider fungal infections - candida or aspergillosus.(tx- amphotericin B or fluconazole)
11. Consider PCP, TB.
12. Granolocyte CSF- seek expert advice.
13. Education- food prep, hand washing, trauma to skin, oral hygiene, no live vaccines. If temp > 38 degrees go to ED.

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Always be aware of shock. Circulatory failure resulting in inadequete organ pefusion. bp <90.>

1. Call for arrest team
2. ABC ( high flow oxygen, consider bagging)
3. Initial work up - sats, glucose level, ECG, CXR, U&E (ARF?), LFT, FBE, CRP, ESR.
4. Septic workup and commence antibiotics (above) if suspected septic shock.
5. Need to correct for hypotension to maintain adequete organ perfusion.
6. IV access with 2 large bore for cystalloid infusion.
7. Consider inotropes(dobutamine) or vasopressors (dopamine, noreadrenalin) via central venous line to maintain a bp of >90mmHg, CVP 8-12mmHg, MAP>65.
8. Achieve a urine output of >0.5mL/kg/hr.