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MANAGEMENT OF

FEBRILE NEUTROPENIA IN ADULTS


GONG Cancer Care Guidelines

Next Review Date: February 2010


Responsibility: Gippsland Oncology Nurses Group
Purpose: Provide comprehensive, current, evidence based guidelines for
management of Febrile Neutropenia in adults to inform standardized
policy and procedure development across Gippsland.
Desired Outcome: Reduce variations in care and promote best practice

1. DEFINITION • Neutropenia exists when there is an absolute decrease in


the number of circulating neutrophils, less than 1.0
(x109/L).
• Febrile neutropenia exists when a patient with a neutrophil
count less than 1.0 (x109/L) has a temperature greater than
or equal to 38oC, or if a patient is systemically unwell with a
clinical suspicion of sepsis.

2. BACKGROUND & • Neutrophils are a sub-type of white blood cells whose


primary purpose is to fight infection, especially bacterial
RISK FACTORS infection.
• Neutropenia may be caused by basic disease processes
such as leukemia. Neutropenia may also occur as a result
of treatment for cancer such as chemotherapy and
radiotherapy.
• Neutropenia is a common adverse effect of chemotherapy,
and it can put patients at risk of severe infection.
• Neutropenia is the single most important predisposing
factor to infection in the person with cancer. Infection is the
most common cause of death in the cancer patient.
• Neutropenia is associated with a profound impairment in
the inflammatory response leading to a reduction of the
usual signs and symptoms of infection such as erythema,
swelling, heat, pain and pus formation.
• Patients with neutrophil counts of less than 1.0 (x 109/L)
have an increased risk of bacterial infection, principally from
endogenously acquired bacteria from skin, nose, and throat
or gastrointestinal tract flora.

3. COMPLICATIONS • The major complication of febrile neutropenia is septic


shock and treatment is directed at preventing the
development of this complication. Early recognition of septic
shock is essential to patient survival.

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4. HIGH RISK PATIENTS Patients with cancer plus at least one or more of the following
factors:
• Haematological malignancy
• Myelosuppresive chemotherapy
• Concurrent chemotherapy and radiotherapy
• Age >60
• Co-morbidities eg. Diabetes, poor nutritional status.
• Bone marrow involvement of cancer
• Delayed surgical healing or open wounds
• Significant mucositis
• Unwell (eg hypotensive, oliguric)
• On steroid dose >25mg prednisolone daily
• Rapidly falling neutrophil count
• History of neutropenia
• Recent hospitalisation for infection

5. LOW RISK PATIENTS Patients with cancer and:


• Solid tumour (non-haematological malignancy)
• Not unwell at presentation
• No mucositis
• No co-morbidities
• Neutrophil recovery likely in the next week
• Normal blood and urine cultures
• Normal chest x-ray
• No suspicion of line sepsis

6. INITIAL ASSESSMENT Careful history and physical examination including:

(TRIAGE) • Type of cancer and recent treatment.


• Temperature, pulse, respiratory rate, blood pressure and
Chemotherapy patients who oxygen saturation
present with a fever greater
than 38oC will be assumed Physical exam focusing on:
to be neutropenic unless
• Chest
there is a white cell count
within the previous 24 • Mucous membranes
hours to the contrary.
• Skin
• Venous access devices
Patients three months or • Peri-anal area
less after a bone marrow
• Urinary tract
transplant will be
considered to be equivalent • Gastrointestinal Tract
to a neutropenic patient in
• Remember that signs of infection may be subtle or absent
risk and treated accordingly
as neutropenic patients may exhibit little or no
independent of the
inflammatory response
neutrophil count.

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6.1. Recommended Initial • Blood tests: FBE, U&Es, LFTs, peripheral blood cultures,
Investigations coagulation profile, CRP
• Central line blood cultures (if patient has a central venous
access device)

NB. Do not flush central venous access device before


withdrawal of blood for blood cultures

• Do not discard initial blood specimen when taking blood


from central venous access devices for blood cultures, use
initial sample for blood culture
• Mid stream urine sample
• Sputum for M/C/S if patient has a productive cough
• Faeces for M/C/S and Clostridium difficile toxin if there is
diarrhoea
• Swab all wounds, recent IVC site, central venous access
sites
• Chest x-ray
• Lumbar Puncture only after consultation with managing
doctor.

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6.2. Recommended
Antibiotic Therapy

Intravenous antibiotics should be administered within 30 minutes of presentation


to the Emergency Department,
after blood cultures have been collected

HIGH Patient Risk LOW

INITIAL THERAPY Ciprofloxacin


Ceftazidime 2g IV every 8 hours If the patient has a previous
immediate or severe INITIAL THERAPY
OR hypersensitivity to penicillin or Ceftazidime 2g IV every 8 hours
Ciprofloxacin (see Cipro note) cephalosporin then substitute
OR
PLUS ceftazidime with ciprofloxacin
400mg IV every 12 hours Ciprofloxacin (see Cipro note)
Gentamicin IV every 24 hours
(modify dose in renal
(see dosage note) impairment)

Gentamicin
Dose according to age, weight
and renal function as per
Therapeutic Guidelines
IF VASCULAR ACCESS LINE Antibiotic. Monitor levels.
Age <30years - 6mg/kg
OR PORT SEPSIS is Age 30 to 60 years - 5mg/kg
suspected Age >60years - 4mg/kg
Add Vancomycin (to the above
regimen) 1g IV every 12 hours Vancomycin
(modify dose in renal impairment) Infuse slowly at 10mg/minute,
monitor blood levels and adjust
dose accordingly, see
Therapeutic Guidelines
Antibiotic-Monitoring and
dosing of vancomycin

IF CLINICAL OROPHARYNGEAL
CANDIDIASIS OR RECENT HIGH DOSE
STEROIDS
Add Fluconazole 400mg IV
or orally every 24 hours

IF UNRESOLVED FEVER AT 48 HOURS


As well as negative cultures and no clinical indication of site of sepsis,
consider adding Vancomycin. If fever persists a further
48 hours, consider addition of Fluconazole 400mg IV daily

NOTE:
1. Antibiotics should be modified on the basis of culture results.
2. Management of unresolving fever in the context of neutropenia should not be a matter of routine
following of an antibiotic protocol, but should be based on daily clinical assessment, daily assessment of
the full blood count, regular review of culture results, with repeated cultures and other investigations as
required.
3. High resolution CT of the chest is often helpful if there is ongoing fever.
4. The choice of antibiotics should always be modified according to clinical circumstances, e.g. if chest
infection is strongly suspected at the outset, consideration should be given to pathogens such as
Legionella and to the possibility of pneumocystis pneumonia.

Reference: Therapeutic Guidelines-Antibiotic 2006. Severe sepsis – febrile neutropenic patients. Pages 257-258

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7. PRINCIPLES OF • For high risk patients intravenous fluids should be
commenced immediately.
ONGOING CARE
• Administer antibiotics as ordered immediately after blood
culture collection.

NB. Do not delay administration of antibiotics while waiting


for results of pathology investigations unless advised by
medical oncologist, physician.

• Assess vital signs at least every four hours, document and


report changes. Assess vital signs more frequently if:
temperature > 38oC or <36oC, Blood Pressure <90 systolic
or a drop of >40mm Hg, pulse > 90, respiratory rate >20,
oxygen saturation <90%; document and report changes.
• Administer anti-pyretics as ordered by medical officer, do
not nurse initiate anti-pyretics, fever may be masked by
antipyretics.
• Cleanse hands thoroughly before and after all direct patient
contact. Ensure staff caring for the neutropenic patient
have no sign and symptoms of infection.
• Give nursing care to neutropenic patient first to decrease
the risk of cross-contamination.
• Provide and encourage meticulous skin, peri-anal and oral
hygiene for patient.
• Assess skin and mucous membranes eg. Mouth and perianal
areas each shift. Document in medical record and report
changes.
• Observe IV site and Central Venous Access Device site (if
relevant) each shift, document and report changes.
• Do not administer rectal medication unless specifically
ordered by medical staff.
• Do not insert in-dwelling catheter unless specifically ordered
by medical staff. If insertion necessary then aseptic
technique must be observed
• Do not allow live plants or cut flowers in standing water in
room
• Avoid all sources of stagnant water in room such as water
jugs, denture cups, respiratory therapy equipment-change
all daily.
• Screen visitors for illnesses. Encourage visitors to use clean
hand precautions when caring for all patients.
• Use standard precautions when caring for all patients.

8. PAEDIATRIC CARE • For paediatric management of febrile neutropenia refer to


the Royal Children’s Hospital Clinical Practice Guidelines at:
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5201

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REFERENCES
1. Bairnsdale Regional Health Service (2005). Management of Febrile Neutropenia-procedure.
Bairnsdale Regional Health Service Policies and Procedures.
2. Box Hill Hospital Pharmacy Department (2004). Guidelines for treating Fever of Unknown Origin
in Neutropenic Patients. Haematology/Oncology Unit.
3. Mank, A & van der Lelie, H. (2003). Is there still an indication for nursing
patients with prolonged neutropenia in protective isolation? An evidenced-based nursing and
medical study of 4 years experience for nursing patients with neutropenia without isolation.
European Journal of Oncology Nursing. 7(1), 17-23.
4. Miaskowski, C & Buschel, P. (1999). Oncology Nursing-Assessment and Clinical Care. Mosby,
St.Louis.
5. Otto, S. (2001). Oncology Nursing 4th ed. Mosby, St Louis. pp 917-947.
6. Royal Children’s Hospital (2005). Fever neutropenia. Clinical Practice Guidelines.
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5201
7. Royal Women’s Hospital (2005). Febrile Neutropenia: Management. Clinical Practice Guidelines.
http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3315
8. Scarlett, J. (2006). Personal Communication.
9. Shelton, B. (2003). Evidenced-based care for the neutropenic patient with
leukemia. Seminars in Oncology Nursing. Vol 19, No 2 (May), 2003: pp 133-141.
10. Yarbro, C., Hansen-Frogge, M., & Goodman, M. (2005). Cancer Nursing Principles and Practice,
6th ed. Jones and Bartlett, Massachusetts. pp 698-722
11. Therapeutic Guidelines-Antibiotic 2006. Severe sepsis – febrile neutropenic patients. Pages 257-258

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