FACT SHEET

Emergency Department management of adults receiving chemotherapy with symptoms or signs of potential sepsis CRITERION
Any patient who is receiving chemotherapy, whether known to be neutropenic or not, who presents with fever, chills, rigors or unwell.

Issued: August 2012 Immunology & Infectious Diseases Microbiology, Hunter Area Pathology

ANTIBIOTICS
Use one of the following options after assessing patient for a history of penicillin allergy: Piperacillin/tazobactam 4+0.5 g IV 8-hourly (preferred first line option) Ceftazidime 2g IV 8-hourly (option for patient with non-immediate penicillin allergy)

PROCESS
1. Triage the patient as category 2 2. Follow the CEC Adult Sepsis Pathway (overleaf) 3. Perform a thorough history and examination and consider decisions based on presumed cause of presentation 4. Perform investigations (below) PRIOR to administration of antibiotics. Do NOT delay treatment while awaiting results 5. Commence recommended empiric antibiotic(s) (below). Benchmark for administration of antibiotics is less than 1 hour from triage 6. Discuss the patient with the supervising Haematologist or Oncologist as soon as possible

Vancomycin should NOT be used presumptively in febrile neutropenic patients unless the patient is in shock, is known to be colonised with methicillinresistant Staphylococcus aureus (MRSA) or has clinical evidence of a catheter-related infection in a unit with a higher incidence of MRSA infection (ie. Calvary Mater Hospital). If any of these criteria are met, ADD vancomycin to the above regimen: Vancomycin 1.5 g IV, 12-hourly (adjust initial dosage for renal function and monitor blood concentrations, see Therapeutic Guidelines Edition 14, appendix 2.3; slow infusion required). Patients with an immediate type penicillin-allergy Consult supervising Haematologist, Oncologist or Infectious Diseases Physician on-call via telephone 49213000. Immediate hypersensitivity is characterised by the development of urticaria, angioedema, bronchospasm or anaphylaxis (with objectively demonstrated hypotension, hypoxia or tryptase elevation) within one to two hours of drug administration.

ROUTINE INVESTIGATIONS
Blood cultures: two sets collected from separate peripheral venipunctures (20 mL each set in an adult, 3-5mLs in a child). Collection from a preexisting intravascular device should only be done as a last resort or after direction by supervising Haematologist or Oncologist and must follow correct aseptic practice. FBC, calcium, electrolytes and LFTs Mid-stream urine

REFERENCES
Blood culture collection procedure (CEC) Clinical Excellence Commission, Adult Sepsis Pathway Therapeutic Guidelines: Antibiotic, Edition 14 Hunter New England Sepsis Adult First Dose Empirical Antibiotic Guideline

CEC Adult Sepsis Pathway- assessment section

(see full version for resuscitation guideline)