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Oncology - care of the oncology patient admitted to PICU with febrile neutropenia

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Fever

  • > 38 deg C (oral or tympanic) on two consecutive occasions > one hour apart OR
  • > 38.5 or on one occasion (oral or tympanic)

Neutropenia

  • A neutrophil count of <0.5 x 109/L
  • OR recent intensive chemotherapy where neutropenia is expected for 8 to 14 days post start of chemotherapy.

Evaluation of a patient with a temperature spike

  • Examine patient
  • FBC, urea and electrolytes. If pt has history of coagulation issues check coagulation bloods
  • Culture blood from ALL central line lumens (prior to administration of antibiotics)
  • Peripheral blood culture
  • Culture other sites as clinical indicated (sputum, tracheal aspirate, NPA, urine, stool, pleural)
  • Chest X-ray as clinically indicated
  • Check Multi-resistant organisms status and/or for clinical alerts

Initial Treatment

  • Ticarcillin/clavulanic acid IV 75mg/kg (max 3g) Q6H (as ticacillin content)
    AND Amikacin IV 20mg/kg (max 1.5g) once daily.
  • Antibiotic therapy to be commenced within 1 hour of presentation of fever spike
  • Culture all lumens every 24 hrs if the patient remains febrile
  • Cycle the antibiotics administration through the different lumens

Specific High Risk Subgroups

'Shocked" septic patients

  • Start with Amikacin, Ticarcillin/clavulanic acid and Vancomycin
  • If Cisplatin exposure, use Meropenem and Vancomycin

AML- Post high dose cytarabine (HD ARA-C) AND BMT - Post BuCy conditioning

  • High risk for Steptococcus mitis infection
  • Start with Amikacin, Ticarcillin/clavulanic acid and consider adding Vancomycin
  • Review after 48 hrs

Prior or planned Cisplatin exposure

  • Need to avoid nephrotoxic/ototoxic agents
  • Start with Ceftazidime as substitute for Amikacin and Ticarcillin/clavulanic acid
  • If other high risk factors present then use Meropenem

ESBL colonised patient

  • If ESBL Amikacin-sensitive - use Amikacin
  • If ESBL Amikacin-resistant or sensitivities unknown - use Meropenem
    • If organism is shown to be susceptible to other antibiotics, switch ASAP
    • Avoid prolonged courses of 3rd generation cephalosporins - consider stopping antibiotics when afebrile

Evaluate after 48 hours

All culture results should be review and antibiotics adjusted according to isolates and antibiotic sensitivities

  • If afebrile with negative cultures and still neutropenic, consider change to Ceftriaxone and Amikacin
  • Antibiotics to continue until neutrophil count >0.5 x 109/L

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Document Control

  • Date last published: 10 June 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Fiona Miles
  • Editor: John Beca