dr katherine watson st1 microbiology antibiotic management of neutropenic sepsis at the james cook...
TRANSCRIPT
Dr Katherine Watson ST1 Microbiology
Antibiotic Management of Neutropenic Sepsis at
The James Cook University Hospital
Introduction Review of trust antibiotic policy using:
Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients. NICE Guidelines, September 2012
Local antibiotic resistance rates in gram negative bacteraemias
NICE Guidelines
All patients should be offered:
Prophylaxis with fluoroquinolone antibiotics during expected periods of neutropenia
Piperacillin/tazobactam as initial empiric antibiotic therapy
Aminoglycosides not recommended
“Unless patient specific or local microbiological contraindications”
Current Trust Antibiotic Policy Neutrophil count < 1.0 x 10 9 /L plus any of the following:
Temp. > 38oC at any time Rigors Hypothermia Unexplained hypotension Unexplained deterioration without pyrexia
Patients must receive intravenous antibiotics within 1 hour of presentation
First Line Antibiotic (pending culture results)Piperacillin/Tazobactam 4.5g tds
+ Gentamicin 5mg/kg stat
Methods APEX search
Positive blood cultures for patients under care of haematology consultants
Information recorded: Organism identification Antibiotic sensitivities of gram negative bacteria
Piperacillin/tazobactam, meropenem, ciprofloxacin, gentamicin
Positive Blood Cultures
512 positive blood culture bottles taken between February 2009 and October 2012
151 patients
600 organisms cultured 267 gram positive bacteria (44.5%) 329 gram negative bacteria (54.8%) 4 fungi (0.7%)
Bacteria Identified
329 Gram negative bacteria: 108 E.coli 33.0% 103 KESC group 31.3% 60 Pseudomonas sp. 18.2% 23 Stenotrophomonas maltophilia 6.9% 11 Acinetobacter sp. 3.3% 24 Other gram negative bacteria 7.3%
Antibiotic ResistancePip/tazo Meropenem Ciprofloxacin Gentamicin
S R S R S R S R
E.coli 99 9 108 0 105 3 107 1
Pseudomonas sp.
59 1 50 10 59 1 59 1
KESC group 86 17 103 0 94 9 95 8
Acinetobacter sp.
11 0 11 0 11 0 7 4
All others 12 8 7 3 18 3 17 2
Total 88% 12% 96% 4% 94% 6% 95% 5%
S=sensitive, R= resistant. Not all organisms have full sensitivities available on APEX, S. Maltophilia not included as poor correlation between antibiotic susceptibility and treatment outcome
1. Fluoroquinolone Prophylaxis
However concerns regarding:Risk of antibiotic associated Clostridium difficile Development of antibiotic resistance
Action Use of fluoroquinolone prophylaxis still under
consideration
94% of gram negative bacteria sensitive to ciprofloxacin
2. Piperacillin/tazobactam
35 piperacillin/tazobactam resistant gram negative bacteria
12 individuals, 2 with recurrent bacteraemias
Action Continue to use as part of first line treatment of
neutropenic sepsis Not to use as a single agent
Local resistant rate of 12% in gram negative bacteria
3. Aminoglycosides
Only 2 bacteraemias resistant to both piperacillin/tazobactam and gentamicin
Action Gentamicin will continue to be given for at least
the first 24 hours after admission To be reviewed with clinical response and culture
results
99.2% of gram negative bacteria sensitive to either piperacillin/tazobactam or gentamicin
Conclusion First line treatment of neutropenic sepsis
to remain as piperacillin/tazobactam and gentamicin High resistance rates to NICE
recommended empiric agent
NICE guidelines comment on importance of local resistance patterns “High rates of resistance to chosen empiric
agent could lead to treatment failure”
