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Management of neutropenia with a fever, including an antibiotic, anti-viral and anti-fungal policy for this group of patients.
Children with neutropenia and fever, especially children with haematological and/ oncology conditions.
Neutropenia is defined as a neutrophil count of <1 x 109/L and patients who are neutropenic are vulnerable to overwhelming infection. The frequency and severity of infective episodes correlates inversely with the degree and duration of neutropenia and is particularly marked in children whose neutrophil count is below 0.5 x 109/l.
This policy should be read in conjunction with:
IN A NEUTROPENIC PATIENT, THE OCCURENCE OF FEVER MUST BE REGARDED AS AN EMERGENCY
!!!! The first dose of antibiotics can precipitate septic shock!!!! Prepare to resuscitate the patient
Additional investigations should be performed:
Antibiotic doses in this SOP are appropriate for empirical treatment or sensitive organisms only. For any organism categorised as 'I' (Susceptible - increased exposure), seek further advice on appropriate dose selection.
Dosing regimen: Tazocin (90mg/kg/dose 4 times a day) plus Gentamicin (7mg/kg/once daily)
NB: Piperacillin increases the risk of toxicity when given with Methotrexate. For any patient imminently due IV Methotrexate or who is post Methotrexate and has not cleared to acceptable levels, prescribe Meropenem as first line empirical therapy.
Vancomycin, rather than Teicoplanin should only be used in patients suspected to have a line related infection and who are septicaemic.
Dosing regimen: Meropenem (20mg/kg/dose three times a day)
plus/minus Gentamicin (7mg/kg/once daily)
This depends on the degree and duration of neutropenia and the organism cultured, but as a general rule:
For children aged 1-18 years:
NB: Do not forget to indicate on the microbiology request form the actual time the sample was taken – levels taken outwith the recommended times can still be interpreted, if an accurate sampling time is recorded.
Withhold oral chemotherapy for Acute Leukaemia patients. Refer to individual treatment protocol /guidelines for other haemato/oncology patients to establish if chemotherapy should be stopped temporarily in the neutropenic patient. Note: In certain protocols, chemotherapy is continued even in the presence of neutropenic fever. Discuss with consultant.
The child should be examined daily for signs of infection including sites such as the mouth, axillae, ears, perineum and central catheter site.
Continue prophylaxis co-trimoxazole whilst other antibiotics are being given unless the patient is receiving high dose co-trimoxazole intravenously or consultant thinks that co-trimoxazole should be temporarily discontinued to allow count recovery. Prophylaxis need not be given intravenously but can be temporarily withheld in patients who are nil by mouth.
1-23months:100-200mg x 5/day for 5 days
2-17 years: 200-400mg x 5/day for 5 days
1-23 months: 200mg x4/day for 5 days
2-5yrs: 400mg x4/day for 5 days
6-11yrs: 800mg x4/day for 5 days
12-17yrs: 800mg x5/day for 5 days
3mo – 12 years: 250-500mg/m2 three times daily.
12-18 years: 5-10mg/kg three times daily
This SOP will be reviewed in 24 months time.
Criteria for treatment
Last reviewed: 01 November 2021
Next review: 01 November 2022
Author(s): J Sastry
Approved By: Sch Clin Gov Group
Document Id: HAEM-ONC-003