5. Septicaemia

Take cultures

Assess the likely site of origin, the likelihood of MRSA, and see appropriate guidance (e.g. section 11 Gastrointestinal system for biliary sepsis)
Start antibiotics immediately

Infection	Treatment (IV)	Duration
Non-neutropenic sepsis unknown origin	Imipenem 500mg QDS* plus gentamicin 5mg/kg OD* (See protocol for dose. Monitor levels) If history of CNS disease (e.g. epilepsy, head injury) use meropenem 1g TDS* in place of imipenem	Review after 5 days
Neutropenic sepsis Neutropenia is defined as neutrophil count <0.5 x109 /L	For patients that have received recent chemotherapy refer to the POU guidelines below or contact the hospital managing the chemotherapy treatment For non-chemotherapy patients: Imipenem 500mg QDS* plus gentamicin 5mg/kg OD* (See protocol for dose. Monitor levels) If history of CNS disease (e.g. epilepsy, head injury) use meropenem 1g TDS* in place of imipenem	Review after 5 days

*For patients with renal impairment refer to section 23 for dosage adjustments

Patients that have received platinum based chemotherapy (cisplatin or carboplatin) should NOT receive gentamicin

Consult microbiology for further advice.

Protocol for action when patient phones POU unwell (or attends A&E)

If chemotherapy received within last 4 weeks patient must be seen on POU same day

If no recent chemotherapy and clearly patient ill try and decide which is best option:-

• attend POU today / tomorrow
  

• call out GP now
  

• bring forward clinic appointment

The choice depends on problem, family distress, closeness to POU, if GP has been supportive and knows them - not on how busy you are. Always think what if this was my relative, what would I do?

Patient had recent chemotherapy

Nb. Neutropenic patients may die suddenly of sepsis. They may not develop a fever if septic, especially if they are on steroids.

You must exclude infection as cause of morbidity.
If they are clearly ILL they must be admitted, preferably to POU, but if we are full a borrowed bed in hospital.
If no beds are available contact the Bed Manager. If there are no beds at Wythenshawe, discuss with SpR but consider transfer to referring consultant, or consider Christie Hospital.

Check

• Pulse, temp, respiratory rate, blood pressure
  

• FBC, differential, U&Es, calcium and blood glucose
  

• Blood cultures (peripheral and central if PICC or Hickman line) - especially if you suspect infection because of fever, or lethargy or generally ill around 10-14 days post chemo
  

• Culture sites of infection, e.g. sore throat, MSSU, sputum, long line entry site
  

• Consider viral cultures if "flu-like" illness
  

• If diarrhoea is present send stools sample for C. difficile toxin (CDT). If Diarrhoea is severe give metronidazole 400mg TDS. Stop metronidazole if CDT negative

Follow treatment chart and antibiotic guidelines to decide management according to whether patient well or ill, considering patients allergies to antibiotics

IF IN DOUBT ADMIT

 POU Antimicrobial policy for neutropenia

• Neutropenia is defined as neutophil count <0.5 x 109/l
  

• Absence of fever does not exclude the presence of infection
  

• Take blood cultures
  

• Take specimens for bacterial and viral cultures as appropriate

NOTE: Patients that have received platinum based chemotherapy (cisplatin or carboplatin) should NOT receive gentamicin

	No penicillin allergy Refer to section 3 (allergies)	No penicillin allergy Refer to section 3 (allergies)
Antibiotics to be started immediately and for patients with renal impairment refer to section 23 for dosage adjustments
Treatment A IV	Imipenem 500mg qds IV	Teicoplanin 400mg bd x 3 doses then 400mg once daily IVPlus Gentamicin 5mg/kg IV single daily dose. Max 400mg. (See protocol for dose. Monitor levels) Monitor renal function carefully
Or
Treatment A Oral	Ciprofloxacin 500mg bd oral Plus Coamoxiclav 625mg tds oral if chest infection signs/symptoms	Ciprofloxacin 500mg bd oral Plus Clarithromycin 500mg bd oral if chest infection signs/symptoms
Clinically septic - very ill, high fever, septic shock
Treatment B IV	Imipenem 500mg qds IV Plus Gentamicin 5mg/kg IV single daily dose. Max 400mg. (See protocol for dose. Monitor levels) Monitor renal function carefully Or Ciprofloxacin 500-750mg BD if had platinum chemotherapy	Teicoplanin 400mg bd x 3 doses then 400mg once daily IV Plus Gentamicin 5mg/kg IV single daily dose. Max 400mg. (See protocol for dose. Monitor levels) Monitor renal function carefully
Nb. If no better in 24 - 48 hrs seek advice from microbiologists Consider immediate commencement of daily G-CSF s/c if clinically septic

POU Antimicrobial policy for neutropenia

Alter antibiotics in light of bacteriology reports

Duration of antibiotics

Patients should receive a minimum of 5 days therapy

Patients with neutrophil count greater than/equal to 500/mm3
- stop antibiotics if patient has been apyrexial for 3 days if:

a) cultures indicate organism eradicated
b) all sites of infection have resolved
c) patient free of signs and symptoms
d) falling acute phase reactants eg CRP

Patients with neutrophil count less than 500/mm3
-low risk and above factors a) to d) met,
 stop antibiotics when patient has been afebrile for 5-7 days

-high risk (eg if patient has mucositis, ulcers, bleeding points, iv-catheter site infection present or if invasive procedures or ablative chemotherapy pending)

continue antibiotics so that patient receives at least 10 days treatment in total or until neutrophils >500/mm3

Patients who have antibiotics stopped while they are still neutropenic should be monitored closely for signs of infection and fever and if these occur intravenous antibiotics should be started again

Decision Table for the Management of POU Patients Who Have Had Recent Chemotherapy (within 4 weeks) and May Have Infection