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Related Subjects: |Hypercalcaemia |Neutropenic Sepsis |Pulmonary Embolism |Superior vena caval obstruction syndrome |Cerebral Metastases |Metastatic bone disease |Oncological emergencies |Neutropenia |Neutrophils

Usually seen 10-12 days post-chaemotherapy with neutrophil count < 0.5 x10⁹/L. There is a loss of innate immunity causes patients to be susceptible to life-threatening infection. Needs IV Broad-spectrum antibiotics. Take expert advice if fever persists. Death can come quickly in a neutropenic febrile patient.

About

• Medical/Haem/Oncology emergency
• Isolate, culture and treat quickly

Severity

• Mild Neutropenia: 1000-1500 cells/mm³
• Moderate Neutropenia 500-1000 cells/mm³
• Severe Neutropenia < 500 cells/mm³
• Fever: One reading = 38.3°C or = 38.0°C for over 1 hour,
• Caveat: the absence of fever does not indicate the absence of infection
• Hypothermia on presentation has a higher correlation than fever
• Cancer itself can cause fever

Definition

• Neutropenia: Defined as neutrophils = 1.
• Functional neutrophilia - following recent chaemotherapy even with levels >1
• Myelodysplastic patients have functional neutropenia even with "normal" neutrophil levels.
• Patients attending haematology OPD monthly, are at risk of neutropenia.
• Risks increase as count falls from 1 to 0.5 x10⁹/L

Common aetiology

• Cancer patients where malignant cells in bone marrow crowd out the functional cell precursors
• Cancer Patients treated with cytotoxic anticancer agents, which, by design, are particularly lethal to cells with rapid turnover.
• Others: Carbimazole, Viral, Brucella, TB, Check all drugs

Background

• Commonest causes are Escherichia coli and coagulase-negative Staphylococcus,
• E Coli from bowel. Staphylococcus from skin
• Fungal infections are uncommon unless prolonged neutropenia/broad spectrum antibiotics
• 3rd generation cephalosporin use is associated with C difficile and Vancomycin resistant enterococci

Clinical

• Full Exam, Temperature > 37.5°C
• Fever, rigors, diarrhoea, malaise
• Sore throat, Cough, sputum, Dysuria
• Pulse, BP, mouth, chest, perineum, line sites, skin, fundi.

Investigations

• FBC, U&E Cr., LFT, CRP, CXR
• Sinus or dental x rays if symptomatic
• Blood cultures, Urine
• Blood cultures, Urine dipstick and culture, Check peripheral and central line if present
• Culture any lines e.g. Hickman lines
• Swabs from appropriate inflamed sites
• MSU if symptomatic
• Faeces if diarrhoea and/or if fungal infection suspected, check C. difficile toxin
• Aspergillus precipitans and PCR
• Serology, mouthwash, vesicle fluid for virology if indicated
• Persisting: CT abdomen/pelvis to exclude foci of pus

Proceed with urgency if

• SBP <90 mmHg or MAP <65 mmHg
• New need for oxygen to achieve saturation >90%
• Lactate >2 mmol/L (following administration of fluid bolus)
• Urine output <0.5 ml/kg for 2 hours - despite adequate fluid resuscitation
• Acutely altered mental status
• Glucose >7.7 mmol/L (in the absence of diabetes)
• Creatinine >177 micromol/L
• Bilirubin >34 micromol/L
• PTR >1.5 or aPPT>60s
• Platelets <100 x 10⁹/L

Management (Discuss with Haematology/Oncology/Microbiology as appropriate.)

• ABC, Resuscitate. Liaise with microbiologist/haematologist/oncologist
• Culture. Then: Tazocin (Piperacillin/Tazobactam) 4.5g TDS IV initially as Anti-pseudomonal cover is important for people with suspected neutropenic sepsis,
• Some also recommend Gentamicin 5 mg/kg IV od max 500 mg
• Consider adding Vancomycin 1g bd IV (see Appendix 3) or Teicoplanin if line sepsis is suspected For Penicillin allergy contact Consultant Microbiologist.
• Fever persists after 3-5 days consider antifungals such as Caspofungin
• Growth factors may be considered. Give platelets if Platelet count > 20 x10⁹/L

References

• Managing Patients with Oncologic Complications in the Emergency Department