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Related Subjects: | Neutropenic Sepsis | Oncological emergencies

WRITTEN WARNING MUST BE GIVEN to patients prescribed Carbimazole so that they aware to seek help if any signs or symptoms of agranulocytosis - sore throat. Agranulocytosis is dangerous and affects about 0.3 in 1000 patients and should be suspected in patients on high doses presenting with a sore throat, mouth ulcer or any serious infection and the patient is advised to stop the drug and seek medical help. The risk of agranulocytosis is lower with carbimazole than with propylthiouracil. Agranulocytosis is an absolute contraindication to further treatment with antithyroid drugs and treatment with radio-iodine should be given.

About

• Also see neutropenic sepsis

Aetiology

• The likelihood of sepsis is related to the time that the neutrophil count is less than 1.0 x 10⁹/L.

Causes

• Post Chemotherapy at 7-14 days
• Physiological - Commoner in Black races with levels of 0.8-1.5 x 10⁹/L with no increased risk of infection (even as low as 0.5 x 10⁹/L can be normal)
• Infections - Any overwhelming infection, Brucella, Typhoid, Miliary TB, Viral/protozoal
• Immune - SLE, Autoimmune, Rheumatoid with Felty's syndrome
• Hypopituitary, Hypothyroid, Familial

Some Drug causes: check all in BNF

• Cyclophosphamide, Busulfan, Methotrexate, 5-flucytosine
• Carbimazole and Propylthiouracil
• ACEI
• NSAIDS
• Antimalarials
• Anticonvulsants
• Antidiabetic
• Antibacterial - penicillin, trimethoprim sulfamethoxazole
• Antidepressants
• Antihistamines

Classification of neutropenia

• Mild : 1-1.5 x 10⁹/L
• Moderate : 0.5-1.0 x 10⁹/L
• Severe : < 0.5 x 10⁹/L

Management

• During neutropenia topical antiseptics are used for bathing, chlorhexidine mouthwashes and a clean diet is given
• Human keratinocyte growth factor (Palifermin) may be given to reduce mucositis
• Fever should prompt urgent investigations such as FBC/CRP/U&E, urine and blood culture, consider infected cannula and CXR
• Typically Meropenem/Tazocin are given. Vancomycin added if the central line in place
• If fever persists for 48-72 hours despite broad-spectrum antibiotics then consider fungal infection which may require amphotericin

Antibiotic policy

• Be aware of your own Hospital policy
• Piperacillin/Tazobactam (Tazocin and in US Zosyn) 4.5g tds IV plus Gentamicin IV once daily.
• Consider adding Vancomycin 1g bd IV if line sepsis is suspected