Infection in Immunocompromised Patients

Standard risk Fever and Neutropenia

Management of Standard risk patients after 72 hours intravenous antibiotic treatment

• Ensure risk assessment is complete and appropriate.
• At any stage at ≥72-hour assessment, all antibiotics may be stopped if:
  • Patient afebrile (<37.5ºC) for 48hrs.
  • All blood cultures are negative.
  • Clinical judgment, it is safe to stop antibiotics.
• Repeat daily blood cultures from all lumens if temperature > 38^oC
• Review all culture results regularly. If cultures are positive, repeat blood cultures at 48 hours (to ensure clearance of bacteraemia) and review antibiotics as soon as sensitivities are available.
• Only consider switching antibiotics if clinical deterioration or microbiological infection control team suggestions.
• Even if the patient continues to be febrile, consider whether aminoglycoside can be safely discontinued at 24-48 hours if the patient is clinically stable and blood cultures are negative.
• Close monitoring of CBC, electrolytes and aminoglycoside levels.
• No routine addition of vancomycin or teicoplanin if the fever is not improving (unless microbiological indication or local signs of infection from central venous access device or endoprosthesis).
• For patients with an endoprostheses and clinically well at 48 hours with no positive cultures, teicoplanin should be discontinued.
• Routine removal of central venous access device is not considered unless clinically or microbiologically indicated.

Standard risk patients after 96 hours intravenous antibiotic treatment if persistent fever

• All patients who are febrile and neutropenic at 96 hours should be discussed with the ID consultant.
• Start empirical antifungal treatment.
• Consider early chest CT, abdominal ultrasound for hepatosplenic candidiasis and echocardiogram for vegetations, particularly for patients post hematopoietic stem cell transplant.
• Routine switching of initial empiric antibiotics in patients with unresponsive fever is not considered except in the presence of clinical deterioration or a microbiological indication.
• Routine removal of central venous access devices as part of initial empiric management of suspected neutropenic sepsis is not considered unless clinically or microbiologically indicated.
• The routine addition of glycopeptides (teicoplanin / vancomycin) is not considered unless signs of local infection of central venous access device. Glycopeptides can be given in case of severe mucositis and the fever is unresponsive.
• If the patient continues to be febrile, consider discontinuation of aminoglycoside if patient is clinically stable and blood cultures are negative (if not stopped earlier).

Standard risk patients with persistent fever (> 7 days)

Discuss with ID consultant.

Standard risk patients – duration of intravenous antibiotic therapy

• If blood cultures are negative and the patient is clinically well, discontinue antibiotics once afebrile for 48 hours.
• In cases with Positive blood cultures or bacteraemia due to catheter related infection: continue treatment for at least 10 days from the first negative blood culture. If necessary, discuss the plan with the microbiology team and ID team.
• In case of osteomyelitis, fungal infections and staphylococcus aureus longer treatment is required. Consult the microbiology team and ID team.
• If blood cultures are positive for the following organisms, they should never be treated as ‘contamination’: Gram negative organisms including Pseudomonas aeruginosa, Entero-bacteriaceae (e.g. E coli, Klebsiella spp. Enterobacter spp.), Staphylococcus aureus, fungus (Candida etc.)
• If the patient is on Antifungal, continue until resolution of fever, lack of evidence of fungal infection on radiology, improving clinical signs and rising neutrophil count, usually 24 hours after stopping antibacterial and patient can then be discharged.

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