Page 184 - Essential Haematology

170 / Chapter 12 Haematological malignancy: management

Fever 38°C or higher twice within 1 hour
Fever 38°C or higher and circulatory/respiratory impairment
Afebrile but suspicion of sepsis, e.g. hypotension in
patient on high dose steroids

Investigations
Culture : Blood – peripheral vein
– central venous cannulae
Urine
Swab at potential site of sepsis
FBC/Biochem/CRP
Consider CXR

Treatment
Broad spectrum antibiotic, e.g. meropenem/tazocin
± vancomycin (esp. if central line in place)
Circulatory support if appropriate, e.g. fluids

Resolution of fever Fever persists 48–72 hours
Continue treatment
for 5–10 days after
fever settles Additional antibiotic?
e.g. teicoplanin/vancomycin
Consider use of anti-fungal agents
Change antibiotics?

Figure 12.2 A protocol for the management of fever in the neutropenic patient. CRP, C - reactive protein; CXR,
chest X - ray; FBC, full blood count.
formed and infections are often not localized. Fever cated. Staphylococcus epidermidis is a common
may be caused by blood products or drugs, but source of fever in patients with intravenous lines
infection is the most common cause and fever of and an agent such as teicoplanin, vancomycin or
over 38 ° C in neutropenic patients should be inves- linezolid may be needed. If an infective agent and
tigated and treated within hours. Cultures should its antibiotic sensitivities become known, appropri-
be taken from any likely focus of infection includ- ate changes in the regimen are made. If no response
ing blood from central venous lines and peripheral occurs within 48 – 72 hours, changing the anti-
veins, from urine and mouth swabs. The mouth and biotics or treating a fungal or viral infection are

throat, intravenous catheter site, and perineal and considered.
perianal areas are particularly likely foci. A chest
X - ray is indicated as chest infections are frequent. Viral i nfection
Antibiotic therapy must be started immediately Prophylaxis and t reatment of
after blood and other cultures have been taken; in v iral i nfection
many febrile episodes no organisms are isolated.

There are many different antibiotic regimes in Herpes viruses, such as herpes simplex, varicella
use and a close link with the microbiology team is zoster, CMV and Epstein – Barr virus (EBV),
essential. A typical regimen might be based on a undergo latency following primary infection and
single agent such as a broad - spectrum penicillin are never eradicated from the host. Most patients
®
(e.g. Tazocin ), meropenem or a broad - spectrum with haematological malignancy have already been
cephalosporin. Teicoplanin, vancomycin or an infected with these agents and viral reactivation is
aminoglycoside such as gentamicin may be indi- therefore the most common problem. Aciclovir or