Infection in Immunocompromised Patients

Low Risk Fever and Neutropenia

• The low-risk protocol for Ceftriaxone IV OD or oral antibiotics is applicable only for the following patients:
  • No exclusion criteria on presentation (Appendix 1)
  • Clinically well
  • Neutrophils > 0.5 x 10⁹/l at presentation
• Management of low-risk febrile neutropenic patients at presentation includes:
  • Ceftriaxone IV 100mg/kg once daily for 3-5 days or
  • Co-amoxiclav 25 mg/kg/dose BID for 1 week
• The low-risk protocol for oral antibiotics after 72 hours of IV antibiotics is applicable only for the following patients:
  • No exclusion criteria on admission and at 72 hours (Appendix 1)
  • Negative blood cultures at 48 hours
  • Clinically well
  • Neutrophils > 0.1 x 10⁹/l at 72-hour
  • Fever at 72 hours does not exclude from low-risk protocol.

Management of low-risk patients after 72 hours intravenous antibiotic treatment

• Ensure risk assessment is complete and appropriate.
• At 72-hour assessment, all intravenous antibiotics may be stopped if the patient is:
  • Afebrile (<37.5ºC) for 48hrs.
  • All blood cultures are negative.
  • Clinically well.
• Patient does NOT need oral antibiotics if already afebrile (< 37.5^ºC) for 48h at the time of discontinuing IV antibiotics.
• If the patient remains febrile but blood cultures are negative and the patient clinically well, discontinue IV antibiotics at 72 hours and commence oral co-amoxiclav and ciprofloxacin. Give first dose in hospital to confirm that the patient will tolerate it.
• If allergic to penicillin or co-amoxiclav, consider oral clarithromycin for 5 days.
• Co-amoxiclav dosing regimen is as follow:
  • For patients weighing less than 40 kg the usual dose is 20-60mg/kg/day given in three divided doses
  • For patients weighing ≥40kg the usual dose is 1 gm bid or 375 mg tid.
• Follow up for patients discharged on oral antibiotics or IV OD ceftriaxone:
  • Arrange for review at 96 hours.
  • Arrange for review at 120 hours.
  • Ask the family to monitor and record temperature twice daily.
  • If there is clinical deterioration at any time after discharge, review at the clinic or in ER and admit to ward if necessary.
  • Continued fever for 96 hours should not by itself be a criterion for readmission if the patient is well.
  • Readmit to the ward if fever > 38^oC beyond 96 hours from the start of the febrile neutropenic episode.
  • If readmission is needed, follow the standard febrile neutropenia management protocol as per timeline i.e. start iv antibiotics as per empirical regimen with adjustment for sensitivities of any known organisms and commence antifungal therapy once the patient is febrile >96 hours from the start of the febrile neutropenic episode.
  • For patients who remain at home, oral antibiotics can be discontinued once temperature < 38^oC for 48 hours.

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