Why did it take over a week for doctors to initiate treatment?

Part 3 of a series.

Patients with advanced cancer are particularly vulnerable to infection due to a compromised immune system. Moreover, the typical symptoms of serious infection, such as fever and chills, may be absent in cancer patients. If not identified and treated early, infection can lead to sepsis, a life-threatening reaction of the immune system that causes organ failure, shock, and death, as was the case with my father. It is common practice for cancer patients, particularly those with advanced disease, to receive prophylactic antibiotics before undergoing an invasive procedure, to mitigate the risk of serious infection. Prostate cancer patients with metastatic disease often require an invasive procedure to alleviate the blockage of urine flow into the bladder caused by enlarged lymph nodes pressing on the ureters, the tubes that normally carry urine from the kidneys to the bladder. In such cases, the blockages are bypassed by surgically inserting thin, flexible plastic tubes (nephrostomy tubes) into the kidneys. The tubes are either connected to external urine collection bags or can act as stents within the ureters, re-establishing the flow of urine into the bladder and enabling normal drainage. Although nephrostomy tubes are a valuable solution in such cases, they are considered a common source of infection.

When my father first required nephrostomy tubes during one of his initial hospital admissions, he was given broad-spectrum prophylactic antibiotics by the ward physician in charge of his case. He tolerated the procedure very well and was discharged shortly thereafter. In the weeks that followed, he developed issues with the tubes and his urological oncologist recommended that they are replaced, as they were likely blocked. He was scheduled for an outpatient tube replacement procedure. When I realized that my father had not been prescribed prophylactic antibiotics before the procedure, I requested a prescription from his urological oncologist’s team.

Despite the fact that he had a weakened immune system, I was told that antibiotics were not part of the protocol for a nephrostomy tube change and were unnecessary. Less than a week later, my father was admitted to the emergency department with a Staphylococcus aureus infection that had spread to his blood. He had been feeling unwell for several days, complaining of malaise, drowsiness, and nausea. His family doctor ordered urinalysis and bloodwork, which showed evidence of infection. We rushed him to the ER, where he was admitted and began an intensive six-week course of intravenous antibiotics, the first two weeks during his hospital admission and the rest to be completed as an outpatient.

During these two weeks, the nephrostomy tubes were replaced twice — once to remove any potential source of infection, and a second time before his release, after one of the tubes was accidentally dislodged. We were told that he did not require broad-spectrum prophylactic antibiotics for these tube changes because he was already on a course of antibiotics for the Staph aureus infection, albeit a narrow spectrum one. The infectious disease specialist did, however, advise that leaving the tubes attached to external drainage bags was safer than capping the tubes and using them as stents, given my father’s history of infection and tube blockages. Before the procedure, I consulted with the interventional radiologists who would be replacing the tubes and relayed this information. I was told that as long as there was no identifiable blockage in the new tubes, they would follow their protocol to cap the tubes and leave them unattached to external drainage bags. I insisted, they resisted, and my father was discharged following the procedure.

Less than a week later, we brought him back to the ER, after recognizing his usual symptoms of infection: malaise, drowsiness, and nausea. The new team assigned to his case paid little attention to these symptoms, accepting fatigue and nausea as normal in a patient with metastatic cancer. We knew better. My father’s symptoms were extreme for him, and we recognized the pattern. Diagnostic imaging finally confirmed an infection in his left kidney. It took over a week for doctors to diagnose him and replace his antibiotic with a broad spectrum one. During this painful, frustrating time, I pleaded with his health care team for appropriate antibiotic treatment and infection management. My father was suffering from ongoing, inadequately treated infection, which began the first time his nephrostomy tubes were replaced without prophylactic antibiotics and continued with the subsequent mismanagement of additional tube changes and kidney infection. Within 48 hours of starting the broad spectrum antibiotic, my father’s overall condition improved significantly and his previously elevated white blood cell count decreased, as it did each time antibiotic therapy was initiated over the past month.

Why did it take over a week for doctors to initiate treatment? Occult (hidden) infections are difficult to identify in immunocompromised patients who do not display the classic signs of infection, such as fever or chills. According to his attending physician, they could not identify the source of infection — urine and blood cultures were coming back negative — and my father’s symptoms were vague. Moreover, they argued that his high white blood cell count was due to the cancer itself, not the infection. I insisted that cultures, particularly those from a patient on long-term antibiotics, may not be positive even with an active infection and that regardless of the negative cultures he had a compromised immune system and was exhibiting symptoms that for him were indicative of infection. While it’s true that advanced cancer can cause an elevation in white blood cells, there was a distinct trend in the rise and fall of my father’s white blood cell counts over that month, each fall corresponding to initiation of antibiotic therapy. Yes, he had metastatic cancer, but his blood work, the pattern of his symptoms and his response to antibiotic therapy suggested that the burden of infection, rather than rapidly progressing metastatic disease was the primary cause of his multiple hospital admissions since his first nephrostomy tube change. The late recognition and treatment of serious infection caused a significant decline in his functional status, weakening his already immunocompromised body as the weeks went by.

Iris Kulbatski is a science writer.

Image credit: Shutterstock.com

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