Antibiotic Management of Neutropenic Sepsis at The James

Antibiotic Management of Neutropenic Sepsis at The James Cook University Hospital Dr Katherine Watson ST 1 Microbiology

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. > 38 o. C 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. 5 g tds + Gentamicin 5 mg/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 103 KESC group 60 Pseudomonas sp. 23 Stenotrophomonas maltophilia 11 Acinetobacter sp. 24 Other gram negative bacteria 33. 0% 31. 3% 18. 2% 6. 9% 3. 3% 7. 3%

Antibiotic Resistance Pip/tazo Meropenem Ciprofloxacin Gentamicin S R S R E. coli 99 9 108 0 105 3 107 1 Pseudomonas sp. 59 1 50 10 59 1 KESC group 86 17 103 0 94 9 95 8 Acinetobacte r sp. 11 0 7 4 All others 12 8 7 3 18 3 17 2 4% 94% Total 88% 12% 96% 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 94% of gram negative bacteria sensitive to ciprofloxacin However concerns regarding: Risk of antibiotic associated Clostridium difficile Development of antibiotic resistance Action Use of fluoroquinolone prophylaxis still under consideration

2. Piperacillin/tazobactam Local resistant rate of 12% in gram negative bacteria 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

3. Aminoglycosides 99. 2% of gram negative bacteria sensitive to either piperacillin/tazobactam or gentamicin 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

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”

Any Questions? Katherine. watson@stees. nhs. uk