Neutropenic Sepsis

Potentially fatal complication of systemic anticancer treatment; mortality up to 20%.

Definition: temperature ≥38⁰C, or temperature of ≥37.5⁰C on two occasions recorded 1 hour apart AND neutrophil count ≤1.0×10⁹/L or other clinical signs of sepsis.

Infection should be suspected in any patient who is feeling generally unwell following chemotherapy (within 6 weeks)

Questions

• Has the patient received systemic anticancer therapy within the last 6 weeks?
• Does the patient have a temperature ≥38⁰C, or ≥37.5⁰C on two occasions recorded 1 hour apart?

Unwell Febrile Cancer Patient

• within 6 weeks of chemotherapy
• immuno-suppressed
• history of bone marrow transplant or bone marrow failure due to haematological malignancy

Severe sepsis? Altered mental state, hypoxia or shock

• Resuscitate
• Initiate antibiotics
• Transfer to ICU/HDU

Immediately – within 10 minutes of arrival

OBSERVATIONS: temperature, pulse, RR, BP, Sats O2, Alert Voice Pain Unresponsive (AVPU), monitor urine output EWS score chart

VENOUS ACCESS: Urgent FBC, blood cultures, clotting screen, LFTs, U&Es, CRP, VBG, MSU, stool, sputum, throat swab

Inform senior ED doctor

Move to resus or side room

Consider CXR if clinically indicated – DO NOT DELAY ANTIBIOTICS

Within 30 minutes

Refer to Oncology for URGENT review within 30 minutes

Within 60 minutes

IV ANTIBIOTICS (to be given within 10 MINUTES of being prescribed)

1^st line antibiotics:  piperacillin-tazobactam (Tazocin®) 4.5 grams IV 8 hourly + amikacin 15mg/kg IV stat

1^st line if penicillin allergy

Non-severe allergy (e.g. rash): meropenem 1g IV 8 hourly + amikacin 15mg/kg IV stat dose

Severe allergy (e.g. anaphylaxis): ciprofloxacin 400mg IV 12 hourly + amikacin 15mg/kg IV stat dose + tigecycline 100mg IV stat then 50mg 12 hourly

Initial assessment – patient seen in ED

History to include:

• Has the patient received systemic anticancer therapy within the last 6 weeks?
• Does the patient have a temperature ≥38⁰C, or ≥37.5⁰C on two occasions recorded 1 hour apart?
• Did the patient have bone marrow transplant?
• Is the patient immuno-suppressed (HIV or other)?
• What chemotherapy is the patient on and when was the last treatment/tablet?

See drug specific information sheet

Initial assessment

• Observation: temperature, pulse, RR, BP, Sats O2, Alert Voice Pain Unresponsive (AVPU), monitor urine output
• Early Warning Score (nEWS)
• Investigations: Urgent FBC, blood cultures, clotting screen, LFTs, U&Es, CRP, VBG, MSU, stool, sputum, throat swab
• Consider Chest X-ray if clinically indicated but do not delay IV antibiotics
• Move patient into a side room or resus

Treatment

• IV antibiotics within 1 hour from arrival – within 10 minutes from prescribing
  • 1^st line antibiotics:  piperacillin-tazobactam (Tazocin®) 4.5 grams IV 8 hourly + amikacin 15mg/kg IV stat
  • 1^st line if penicillin allergy:
    • Non-severe allergy (e.g. rash): meropenem 1g IV 8 hourly + amikacin 15mg/kg IV stat dose
    • Severe allergy (e.g. anaphylaxis): ciprofloxacin 400mg IV 12 hourly + amikacin 15mg/kg IV stat dose + tigecycline 100mg IV stat then 50mg 12 hourly
• IV fluids, Oxygen if needed

Once patients are admitted and stable, review previous microbiology results for positive culture results.

• In patients with diarrhoea: add Metronidazole 500mg IV 8 hourly or 400mg PO 8 hourly
• If perineal or gingival infection: add Metronidazole 500mg IV 8 hourly
• If herpetic lesions: add Aciclovir 5mg/kg IV 8 hourly
• If indwelling venous lines or suspected MRSA: add Vancomycin as per Trust vancomycin dosing guidelines