Adult ECAT protocol

Unwell immunocompromised person

A3.5 Published: December 2023 Printed on 19 May 2024

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Any person, 16 years and over, presenting unwell with or without fever, who has recently (within 14 days) received chemotherapy or other potential cause of immunocompromise.

Escalate immediately as per local CERS protocol.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

Unwell immunocompromised person with systemic compromise or shock

Give antibiotics within 30 minutes of starting this protocol if a medical or nurse practitioner is unavailable. See antibiotic management section.
Elderly patients may present with systemic compromise, with or without fever.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting complaint
Onset of symptoms
Trigger (patient-identified source)
Pain assessment – PQRST
Pre-hospital treatment
Past admissions
Medical and surgical history including oncology or haematology diagnosis, recent surgery, invasive procedure or indwelling medical device
Current medications
Immunotherapy or chemotherapy drug regime, and last dosing
Non-prescription drug or alcohol use
Known allergies
Contact with sick people

Signs and symptoms

Confusion, agitation or irritability
Respiratory distress or cough
Tachycardia
Fever, chills or rigors
Abdominal pain
Dysuria, frequency of urination or reduced urine output
Lethargy

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Organ transplant recipient
Recent surgery or wound
Indwelling medical device
Daily corticosteroids therapy
Returned traveller
Concurrent chemotherapy and radiotherapy
Pregnancy
Re-presentation within 48 hours
Multi-resistant organisms alert in medical record
Splenectomy or non-functioning spleen

Clinical

Altered level of consciousness
Shortness of breath
Haemodynamic compromise in the elderly, with or without fever
Poor perfusion, i.e. prolonged capillary refill, mottled skin or cool peripheries
Tachycardia
Hypotension
Abdominal pain, distension or peritonism
Non-blanching rash

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Allocate to protective isolation space, if available Review the patient's febrile neutropenia management plan, if available

Assessment

Intervention

General appearance/first impressions

Position of comfort

Allocate to protective isolation space, if available

Review the patient's febrile neutropenia management plan, if available

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Assessment

Intervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO₂)	Assist ventilation as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93% Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

Assessment

Intervention

Respiratory rate and effort

Auscultate chest (breath sounds)

Oxygen saturation (SpO₂)

Assist ventilation as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93%

Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Proceed to access central venous access device (CVAD), if trained and/or insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg: give 20 mL/kg sodium chloride 0.9% IV/intraosseous bolus once only, maximum dose 1000 mL. give antibiotics. See antibiotic management section If no response in SBP, escalate as per local CERS protocol for further fluid order.

Assessment

Intervention

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

IVC and/or pathology

Proceed to access central venous access device (CVAD), if trained

and/or insert IV cannula, if trained

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg:

give 20 mL/kg sodium chloride 0.9% IV/intraosseous bolus once only, maximum dose 1000 mL.
give antibiotics. See antibiotic management section

If no response in SBP, escalate as per local CERS protocol for further fluid order.

Unwell immunocompromised person with systemic compromise or shock

Give antibiotics within 30 minutes of starting this protocol if a medical or nurse practitioner is unavailable. See antibiotic management section.
Patient without systemic compromise or shock: continue A to G assessment.

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence strict fluid input and fluid output monitoring
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Assessment

Intervention

BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
give 10% glucose 200 mL by IV infusion over 15 minutes, once only
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Focused assessment should not delay antibiotic administration.

Consider relevant focused assessment according to findings.

Precautions and notes

Patients with presumed sepsis are at high risk of clinical deterioration despite initial resuscitation with fluids and antibiotics.
All patients presenting with fever following anticancer therapy should be managed as neutropenic and receive empiric antibiotics, until proven otherwise.
Do not wait for white cell count (WCC) or neutrophil count before commencing antibiotics.
The absence of fever in elderly patients is frequent, and infection should be suspected in those who have acute functional decline, including new or increasing confusion, falls, reduced oral intake and change in urinary habits.

Interventions and diagnostics

Antibiotic management

Suspected febrile neutropenia with systemic compromise or shock: give antibiotics within 30 minutes if a medical or nurse practitioner is unavailable.

Suspected febrile neutropenia without systemic compromise or shock: give antibiotics within 60 minutes if a medical or nurse practitioner is unavailable.

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

Initial antibiotics

Select one:

No known allergies

Give piperacillin + tazobactam (4 g + 0.5 g) IV once only

If known MRSA or risk of colonisation and/or CVAD in situ:

also give vancomycin 25 mg/kg (actual body weight) IV once only, maximum dose 3 g

Non-severe penicillin allergy

Give meropenem 1 g IV, once only

If known MRSA or risk of colonisation and/or CVAD in situ:

also give vancomycin 25 mg/kg (actual body weight) IV, once only, maximum dose 3 g

Life-threatening or uncertain penicillin allergy

If known MRSA or risk of colonisation and/or CVAD in situ:

give vancomycin 25 mg/kg (actual body weight) IV once only, maximum dose 3 g

Gentamicin dosing is based on BMI and whether there is known kidney impairment.

If gentamicin dose calculator available: use the gentamicin dose calculator. It will work out whether to use actual or adjusted body weight.

If no gentamicin dose calculator: use the BMI and adjusted body weight calculator on the webpage.

BMI under 30: use actual body weight for gentamicin dose.
BMI 30 and over: use adjusted body weight for gentamicin dose.

Gentamicin

Only give gentamicin if there is systemic compromise or shock and/or life threatening penicillin allergy.

Gentamicin dosing is based on BMI and whether there is known kidney impairment.

If using Gentamicin Dose Advisor in eMR: use the gentamicin dose calculator. It will work out whether to use actual or adjusted body weight.

If no Gentamicin Dose Advisor: use the BMI and adjusted body weight calculator on the webpage.

BMI under 30: use actual body weight for gentamicin dose.
BMI 30 and over: use adjusted body weight for gentamicin dose.

Do not give gentamicin if patient has:

pre-existing significant auditory impairment or vestibular condition
history of hypersensitivity reaction to aminoglycoside
myasthenia gravis
history of aminoglycoside-induced vestibular or auditory toxicity, or first degree relative has history of same.

If the patient has any of the above contraindications, continue to give the other antibiotics and seek advice about gentamicin.

Use the BMI calculator below to determine whether to use actual or adjusted body weight for gentamicin dosing.

Analgesia

Select pain score:

Pain score 1–3 (mild)

Give paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Pain score 4–6 (moderate)

Give:

oxycodone (immediate release):

16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Pain score 7–10 (severe)

Give one of:

Fentanyl intranasal

16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils

Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device

Fentanyl IV

16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg

Morphine IV

16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg

Morphine IM

16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

If pain does not improve with medication, escalate as per local CERS protocol.

Nausea and/or vomiting

If nausea and/or vomiting is present, give:

metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

Radiology

If chest thought to be source of infection or source is difficult to determine: CXR

Pathology

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

FBC, UEC, LFT, VBG with lactate, Ca/Mg/PO4, group and hold
Urinalysis: mid-stream (preferred), clean catch or catheter urine. Send for MC&S. Keep sample refrigerated if transport delayed
Blood cultures: take two sets of blood cultures from two separate sites. If a patient has a central venous access device in situ, take 1 set of blood cultures from each lumen, and 1 set from a peripheral site
Consider specific fever sources: wound swab, sputum culture, stool culture and respiratory viral screen
Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug	Dose	Route	Frequency
Fentanyl ^{H, R}	16–65 years: 50 microg Maximum dose 100 microg 65 years and over: 25 microg Maximum dose 50 microg	IV/intranasal	Pain score 7–10 Repeat once if required after 5 minutes to maximum dose
Gentamicin	Use actual or adjusted body weight as per BMI guide provided 16–18 years: 7 mg/kg Maximum dose 560 mg 18–80 years: 7 mg/kg Maximum dose 680 mg 80 years and over: reduce dose to 5 mg/kg Maximum dose 480 mg Known kidney impairment and 18 years and over: reduce dose to 5 mg/kg Maximum dose 480 mg	IV	Once only
Glucagon	1 mg	IM	Once only
Glucose 10%	200 mL	IV infusion over 15 minutes	Once only
Glucose 40% gel (0.4 g/mL)	15 g	Buccal	Repeat after 15 minutes if required
Glucose 50%	50 mL	Slow IV injection	Once only
Ibuprofen ^{H, R}	400 mg	Oral	Pain score 1–10 Once only
Meropenem	1 g	IV	Once only
Metoclopramide ^R	Over 20 years: 10 mg	Oral/IV/IM	Once only
Morphine ^{H, R}	16–65 years: 5 mg Maximum dose 10 mg 65 years and over: 2.5 mg Maximum dose 5 mg	Pain score 7–10
		IV	Repeat once if required after 5 minutes
		IM	Repeat once if required after 60 minutes
Ondansetron	4 mg Maximum dose 8 mg	Oral/IV/IM	Repeat once if required after 60 minutes
Oxycodone immediate release ^{H, R}	16–65 years: 5 mg Maximum dose 10 mg 65 years and over: 2.5 mg Maximum dose 5 mg	Oral	Pain score 4–6 Repeat once if required after 30 minutes to maximum dose
Oxygen	2–15 L/min, device dependent	Inhalation	Continuous
Paracetamol ^H	1000 mg	Oral	Pain score 1–10 Once only
Piperacillin and tazobactam	4 g + 0.5 g	IV	Once only
Prochlorperazine	5 mg	Oral	Once only
	OR
	12.5 mg	IV/IM	Once only
Sodium chloride 0.9%	20 mL/kg Maximum dose 1000 mL	IV/intraosseous	Bolus Once only
Vancomycin	25 mg/kg (actual body weight) Maximum dose 3 g	IV	Once only

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

Show

Government of South Australia. Febrile Neutropenia Management Guideline. Australia: SA Health; 2017 [cited 10 Feb 2023]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/
Klastersky J, de Naurois J, Rolston K, et al. Management of febrile neutropaenia: ESMO Clinical Practice Guidelines. Ann Oncol. 2016 Sep;27(suppl 5):v111-v8. DOI: 10.1093/annonc/mdw325
Long B, Targonsky E, Brém E. Just the facts: febrile neutropenia in the emergency department setting. Cjem. 2021 Jul;23(4):445-9. DOI: 10.1007/s43678-020-00055-x
MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Rivera-Salgado D, Valverde-Muñoz K, Ávila-Agüero ML. [Febrile neutropenia in cancer patients: management in the emergency room]. Rev Chilena Infectol. 2018;35(1):62-71. DOI: 10.4067/s0716-10182018000100062
Strasfeld L. Febrile neutropenia. London, UK: BMJ Best Practice; 2022 [cited 10 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-gb/950
Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
Clinical Excellence Commission. Sepsis Management Plan- Adult Sepsis Pathway. NSW Australia: NSW Health,; 2014 [cited 10 Feb 2023]. Available from: https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0005/291803/Adult-Sepsis-Pathway.PDF
Clinical Excellence Commission. Sepsis Kills Program. NSW Australia: NSW Health; 2022 [cited 10 Feb 2023]. Available from: https://www.cec.health.nsw.gov.au/keep-patients-safe/sepsis/program

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Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/unwell-immunocompromised-person

Unwell immunocompromised person

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Circulation

Disability

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Antibiotic management

Initial antibiotics

No known allergies

Non-severe penicillin allergy

Life-threatening or uncertain penicillin allergy

Gentamicin

BMI under 30

BMI 30 and over

Analgesia

Pain score 1–3 (mild)

Pain score 4–6 (moderate)

Pain score 7–10 (severe)

Fentanyl intranasal

Fentanyl IV

Morphine IV

Morphine IM

Nausea and/or vomiting

Radiology

Pathology

Medications

References