Neutropenic sepsis Flashcards

1
Q

Define neutropenic sepsis.

A

Neutropenic sepsis is a potentially life-threatening complication of neutropenia (low neutrophil count).

It is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower.

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2
Q

What is sepsis? What is septic shock?

A

Sepsis is a syndrome defined as life-threatening organ dysfunction due to a dysregulated host response to infection.

Shock - subset of sepsis involving circulatory, cellular and metabolic abnormalities –> higher risk of mortality than sepsis alone

Diagnosis of septic shock:

  • hypotension despite fluid correction and ionotropes AND
  • hyperlactataemia >2mmol/L
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3
Q

What is febrile neutropenia?

A

Febrile neutropenia is the most common complication of anticancer treatment, and describes the presence of fever in a person with neutropenia. Definitions vary.

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4
Q

What are the causes of neutropenia?

A
  • Drugs and treatments:
    • cytotoxic chemotherapy
    • haematopoietic stem cell transplantation
    • immunosuppressive drugs like azathioprine, methotrexate
    • penicillin, carbimazole, phenytoin etc
  • Infections:
    • Viral - HIV, influenza, hep B, CMV, RSV, EBV cause transient BM suppression
  • BM failure -
    • aplastic anaemia,
    • myelodysplastic syndromes,
    • acute leukaemia
  • Nutritional deficiencies
    • B12 and folate
  • Rare
    • Genetic conditions e.g. Kostmann’s syndrome
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5
Q

Which bacterial and fungal organisms are likely to cause sepsis in a neutropenic patient?

A

Gram +ve pathogens (commonly):

  • Staph aureus
  • Enterococcus sp
  • Strep pneumoniae
  • S. pyogenes

Gram -ve pathogens (less commonly):

  • E coli
  • Klebsiella
  • Enterobacter sp
  • Pseudomonas aeruginosa

Fungal:

  • Candida sp
  • Aspergillus sp
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6
Q

What are the risk factors for neutropenic sepsis?

A
  • Severe pre-existing neutropenia of <0.5 x109/L and lasting >7 days.
  • Chemotherapy for leukaemia
  • HSCT
  • Age - infants and over 60s
  • Corticosteroids
  • Antibiotics
  • Advanced malignancy
  • Central venous access device
  • TPN
  • Co-morbidities DM/liver/renal disease
  • Previous surgery
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7
Q

How common is neutropenic sepsis?

A

Incidence increasing probably with use of anticancer drugs and immunosuppressive therapy - febrile neutropenia occurs in about 8 of 1000 chemo patients

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8
Q

What are the signs and symptoms of neutropenic sepsis?

A
  • Suspect if known neutropenia. Unexpected deterioration
  • Features of infection - dysuria, diarrhoea, productive cough
  • General - malaise, agitation, fever (>38oC), chills, shivers, rigors. NB some may not have fever but hypothermia instead.
  • Cardio - Tachycardia, hypotension, slow cap refill - mottled/ashen skin, pallor/cyanosis, cold peripheries
  • Rash - non-blanching in meningococcal disease
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9
Q

What investigations would you do for a patient with suspected neutropenic sepsis?

A

Give 3 - oxygen, antibiotics, fluids (bolus)

Take 3 - blood culture (before abx), serial lactate, urine output hourly

Investigations:

  • Blood culture
  • ABG - lactate, glucose
  • FBC - WCC may be high/low, ?DIC, neutropenia
  • CRP - high
  • Creatinine, urea, electrolytes - dehydration/AKI
  • LFTs - high bil or ALT may show cholestasis
  • Clotting screen - may be abnormal
  • Urinalysis
  • Sputum microscopy and culture
  • CXR, CT
  • Bronchoalveolar lavage - if severe or prolonged
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10
Q

What is the management of neutropenic sepsis?

A
  • ABCDE
  • Oxygen - maintain at 94%
  • IV fluids - monitor fluid balance hourly
  • IV antibiotics - do not delay; piperacillin/tazobactam 4.5g IV every 6hrs [meropenem+gentamicin if penicillin allergic]
  • Serial lactate
  • Check urine output
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11
Q

What are the complications of neutropenic sepsis?

A

Mortality - 1-2% in low risk patients, up to 80% in bacteraemia

Treatment related:

  • Antibiotic-induced fungal overgrowth
  • Antibiotic induced C diff/MDR infections
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12
Q

What is the prognosis with neutropenic sepsis?

A

Mortality declining

Risk of recurrent neutropenia

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