FIRST LINE MANGEMENT OF FEBRILE NEUTROPENIA PATIENTS BEFORE REFERRAL

The standard principles and management of febrile neutropenic patients are described in the website in detail. However if you want to refer the patients, please go through the following tips.

As you are aware that most of the patients with acute lymphoblastic leukemia are on maintanence chemo-therapy for 2 years at least. And also most of the patients with aplasia or myelodysplasia etc..are chronically nuetropenic.

These patients who are off active therapy are advised to contact their family physcicians/doctors for any problems. The most serious problem is the infection in neutropenic patients.

Any fever in a neutropenic patient (esp. if the Absolute Neutrophil Count is less than 500) is very serious and needs parenteral antibiotic therapy urgently as these patients can go into massive septicemia/septic shock. The family doctor can either treat the patient in his own hospital according to the guidelines given in the website or else refer the patient to us. However it is absolutely essential to give the first dose of parenteral antibiotics, even if you choose to refer the patient to us.

I would like to mention few basic practical tips here.

  • Sometimes, when these patients present with fever, and a blood count is done manually, normal results are reported even if the patients are severely neutropenic, which envisages a false sense of security. I am very sorry to say this (not to blame any lab technicians), but due to panic especially by the new staff, this may happen. Always inform the lab that the concerned patient can have a low WBC count of as low as “0”. This will avoid any spurious reports being delivered. Quite a few deaths have occurred without recognizing this fact, and hence it is important to keep this fact in mind. If possible do an automated cell counter analysis or else inform the lab about the possibility of very low counts.
  • If they are found neutropenic, administer intravenous antibiotics, immediately even if you choose to refer the patient for further management
  • These patients can present at any time, some time even in the midnight with fever. Although, it is definitely advisable to send blood cultures before starting antibiotics, if the facilities for blood cultures are not available (esp. in peripheral centres or at odd times even in urban centres) antibiotics should be started even without taking blood cultures.
  • The initial choice of antibiotics, defer depending on the institutions based on the available sensitivity patterns and the guidelines applied in the centre. However, the family doctor can choose a combination of one of the third generation cephalosporin and aminoglycoside. Both these antibiotics should be administered in the proper maximal recommended dose for the concerned patient.
  • If the patients are found to be non-neutropenic (Absolute neutrophil count more than 1,500), there is no need to refer these patients and they can be managed with oral or iv antibiotics as per the clinical condition. However, please keep in mind that patients on immunosuppressive therapy such as steroids, cclophosphamide, cyclosporine etc.. are prone for serious infections even with a normal neutrophil count.
 
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