Infection in Immunocompromised Patients

Patients with cancer are at increased risk of infection as a result of their disease and/or its treatment. Febrile neutropenia is a medical emergency requiring urgent investigation and the administration of intravenous empirical antibiotic therapy within 1-2 hours. Aggressive use of inpatient intravenous antibiotic therapy has reduced morbidity and mortality rates and reduced the need for intensive care management.

Use of axillary temperatures is discouraged due to inaccuracy.

Rectal temperature measurements (and rectal examinations) are avoided during neutropenia to prevent colonizing gut organisms from entering the surrounding mucosa and soft tissues.

Risk Classification

Use the risk assessment form. (Appendix 1)

• At presentation to decide whether a patient can follow the low-risk protocol from the start.
• At presentation and at 72 hours to decide whether a patient can follow the low-risk protocol at 72h of admission.

In the presence of one or more of the exclusion criteria in the risk assessment form at presentation or at 72h, the patient must follow the standard risk protocol. All other cancer patients are considered low-risk and therefore eligible for IV Ceftriaxone OD or oral antibiotics at presentation or oral antibiotics at 72 hours in case of admission. Fever at 72h does not exclude assignment to a low-risk protocol if no other exclusion criteria are present during admission.

Assessment of patients with febrile neutropenia

• The initial clinical assessment of all patients with febrile neutropenia should include all the investigations shown in (Appendix 2).
• CBC counts and determination of the levels of serum creatinine and urea nitrogen are needed to plan supportive care and to monitor for any possible occurrence of drug toxicity. These tests should be done at least every 3 days during the course of intensive antibiotic therapy.
• At least weekly monitoring of serum transaminase levels is advisable for patients with complicated courses or suspected hepatocellular injury or cholestatic disease.
• Serum Markers of Inflammation including C-reactive protein, interleukins-6 and -8, and procalcitonin in neutropenic patients with cancer have demonstrated inconsistent results. The current data are not sufficient to recommend routine use of these tests as a guidance for about antimicrobial use.

Special considerations

• Any patient with a low neutrophil count who appears unwell with or without fever should be treated using fever and neutropenia protocol, even if they are not fitting with the definition of febrile neutropenia.
• Fever documented at home by the parents requires the same urgent treatment as fever recorded in hospital.
• Any patient who is febrile and could be neutropenic should be seen and assessed immediately by a doctor trained in the management of patients suffering from cancer.
• If a patient is febrile and the neutrophil count is not known at presentation, the patient must be assessed immediately while awaiting the results of the urgent full blood count and other work up.
• If a patient is febrile and the neutrophil count is higher than 0.5 x 10⁹/L but expected to fall in the next 24 – 48 hours, empirical antibiotics should be considered.
• If a patient is febrile with neutrophil count higher than 0.5 x 10⁹/L as well as other concerning clinical risk factors such as significant mucositis, or Down syndrome or post HSCT, empirical antibiotics should be started immediately.
• Classic signs of sepsis may be masked by steroids, e.g. during ALL induction and delayed intensification. As in neutropenic patient on steroids who seems unwell, empirical antibiotics should be started.
• The fever should be unrelated to the transfusion of blood products.
• Aminoglycoside levels should be monitored. The specimen can be taken from the central venous access device and should be taken prior to the second dose and twice weekly thereafter.
• Aminoglycoside pre-dose trough
  • The pre-dose trough for gentamicin should be <1mg/l.
  • Dose and/or schedule must be altered if the trough is elevated or the patient has diminished renal function.
  • Monitoring of peak levels are not normally indicated in patients receiving a single daily dose.
  • Amikacin trough monitoring should be discussed with local microbiologist.
  • Method of monitoring is accurate whether gentamicin is given as a slow bolus or even by infusion.

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