Gastrointestinal Tract Infections in the oncology patient

Shared care information

Diarrhoea in the febrile, neutropenic patient is usually due to chemotherapy-induced gastrointestinal mucositis. Occasionally, it may be due to infective organisms which is likely to require antibiotics or other therapy. Please discuss patients with fever and abdominal signs with the paediatric oncologist on call. Stool specimen requests should state fever/neutropenia to ensure that the laboratory knows to do the correct tests.

Clinical features

Gut mucositis is often associated with oral mucositis (see Mouth Care and Mucositis Guideline). It is often characterised by:

• distended abdomen

• generalised tenderness

• reduced bowel sounds

• intermittent cramps.

Infections may have the same presentation but usually have:

• increased bowel sounds.

Investigations

For suspected mucositis:

• Usual febrile neutropenia investigations

• Stool for microscopy and culture

• Stool for rotavirus, adenovirus, if indicated

• Stool C. difficile toxin and culture

• Stool parasites including giardia and cryptosporidium.

Write diarrhoea + vomiting + fever + neutropenia on the forms so that all appropriate tests are performed.

If fever and diarrhoea persist, discuss with microbiology/ID as it is more common for a stool commensal to be implicated in a febrile neutropenic episode than a known pathogen that infects non-immunocompromised GITs.

Clostridium difficile entercolitis

Management

If feasible, discontinue other antimicrobials.

Keep the patient and family in isolation with barrier nursing and separate tolilet facilities. Treat for 10 days with:

• oral/IV metronidazole (10 mg/kg/dose TDS max 400 mg).

For treatment failures, discuss with the Infectious Diseases team. Consider adding:

• oral vancomycin 10mg/kg (maximum 125mg) 4 times daily for 10 days if first recurrence or 14 days for subsequent recurrences. Note: Use injection solution for oral vancomycin dosing.

  • adsorption of oral vancomycin is minimal but monitor levels in patients with renal failure

  • it risks selection of VRE (vancomycin resistant enterococci) therefore use of vancomycin orally must first be discussed with the Infectious Diseases team

  • do not use with cholestyramine (binds vancomycin).

As many as 20% of patients experience recurrence after discontinuation of therapy. In addition to antimicrobial therapy above, consider:

• cholestyramine which binds the toxin and may relieve symptoms. Dose is 4 g given 6 - 8 hourly. Beware - cholestyramine binds vancomycin and other drugs.

Typhlitis

Typhlitis (neutropenic enterocolitis) is a specific abdominal condition that presents in neutropenic patients.

Pathologically, bowel wall ulceration due to mucositis is followed by infection and necrosis in the wall of the caecum. The most frequent organism is Pseudomonas aeruginosa but infection is usually polymicrobial. Sepsis induced hypoperfusion leads to ischaemia and further damage.

Clinical features

• fever

• vomiting

• diarrhoea

• generalised abdominal tenderness which then localises to the right iliac fossa

• fullness may be felt in the RIF

• occasionally there may be sepsis with no localising signs.

Investigations

• Plain abdominal X-ray - decreased gas in RLQ with dilated small bowel

• CT scan - thickened bowel wall or pneumotosis intestinalis

• Blood cultures (positive in about 50%).

Management

• First line antibiotic cover (see antibiotic protocol) should cover gram negatives and anerobic organisms

• NBM and TPN

• Paediatric surgical consult even though 80% can be managed conservatively

  • presence of free air suggests perforation

  • may have persistent bleeding

  • bowel infarction may require surgical intervention

Mucositis

See separate guideline on mucositis and mouthcare