Neutropenic Sepsis or Immunocompromised

NHSL Antimicrobial Guidelines
NHS Lanarkshire

Neutropenic Sepsis or Immunocompromised

Therapy

If Haematology/Oncology patient discuss with appropriate specialist.
NB Check previous microbiology results and TrakCare ALERTs for evidence of multidrug resistant organisms and seek advice from infection specialist.

IV Piperacillin/Tazobactam 4,10 4.5g 6 hourly
+ IV Gentamicin3
Consider for indwelling line
ADD IV Vancomycin3

Consider fungal infection

 

Penicillin intolerance/minor Penicillin allergy
(see below for severe penicillin allergy/anaphylaxis)
IV Vancomycin3
+ IV Aztreonam10 2g 6 hourly
+ IV Gentamicin3

Consider fungal infection

 

Clear history of anaphylaxis with Penicillin or severe/true Penicillin allergy
IV Vancomycin3
+ IV Ciprofloxacin 1,2,8,9,10,12 400mg 12 hourly
(high oral bioavailability – consider switch at 24 hours)
+ IV Gentamicin3

Consider fungal infection

Notes:

Notes

Neutropenic Sepsis is a life threatening emergency.

Definition

Neutropenic (<0.5 x 109 neutrophils / L)

Plus one of the following:

  • Pyrexial (temperature  ≥ 38oC)
  • Clinically unwell even if aypyrexial (symptoms may include fever, sweats, chills, rigors, malaise, respiratory rate > 20/min, tachycardia HR > 90bpm)

If haematology/oncology patient discuss with appropriate specialist. Check TrakCare for multidrug resistant organism colonisation and discuss with microbiology if present.

Consider fungal infection

Immediate Management - Sepsis Six

1.

Oxygen

Correct hypoxia - aim for O2 sats 94-98%

(88–92% for patients with chronic CO2 retention)

2.

Fluid Resuscitation

Start IV fluids - 20ml/kg

Minimum 500ml in first hour

3.

Lactate

Obtain whole blood lactate. Urgent FBC, U + E’s and coagulation

4.

Urine Output/Fluid Balance Measurement

Consider Urinary Catheter

5.

Infection Screen

Blood Cultures in all patients. Send additional samples relevant to source of sepsis.

6.

Drug Therapy

IV Antibiotics (all required antibiotics initiated within 1 hour)

Doses may need to be adjusted in renal impairment. Always check the BNF for interactions. Seek advice if patient pregnant.

Drug Specific Cautions:

  1. Check interactions in the BNF. Caution may prolong QT interval.
  2. Avoid / Caution in pregnancy or breastfeeding. Consult BNF for details.
  3. Gentamicin/Vancomycin refer to online calculators.
  4. ALERT Antibiotic - Consult Second line Policy on NHS Lanarkshire Guideline App.
  5. Monitor sodium.
  6. See CURB65 definition.
  7. Reference: The Renal Drug Handbook. Online access.
  8. See Fluoroquinolones MHRA guidance on NHS Lanarkshire Guidelines App.
  9. Doxycycline and quinolones decreased absorption with iron, calcium, magnesium and some nutritional supplements. See BNF appendix 1 or pharmacy for advice.
  10. Caution in renal impairment – see BNF or pharmacy for advice.
  11. Use with caution may increase K+ and decrease renal function. Monitor.
  12. High / Excellent oral bioavailability, IV route available for NBM or vomiting.
  13. See Co-trimoxazole information for prescribers’ safety sheet on NHS Lanarkshire Guidelines App.

Editorial Information

Last reviewed: 01/12/2022

Next review date: 01/12/2025

Author(s): NHS Lanarkshire Antimicrobial Management Committee, Dr Dundas, Dr Hylands, S McCormick.

Approved By: NHS Lanarkshire Antimicrobial Management Committee

Reviewer name(s): NHS Lanarkshire Antimicrobial Management Committee.

Document Id: March 2023