Neutropenic Sepsis Flashcards
What is cancer?
rapid proliferation of a cell in the body
- uncontrolled cell growth
How is cancer treated?
intent vs timing
intent
- palliative = control symptoms/prolong life
- curative = cure the cancer
timing
- neo-adjuvant = before the surgery to downsize the tumour, increasing surgical access
- adjuvant = after the surgery to remove micro-metastases and reduce risk of recurrence
What is cytotoxic chemotherapy? What cells can be targeted and what is their side effects?
cytotoxic chemotherapy
- medicine that act by targeting rapidly dividing cells
= are preferentially targeted over other slower dividing cells in the body
other cells can be affected and have toxicities
- blood cells (RBCs/WBCs/Platelets) = anaemia, neutropenia, thrombocytopenia
- hair cells = alopecia
- mucous membranes = ulceration
- germinal cells = can reduce fertility
How is chemotherapy given? What is an example?
chemotherapy is given in cycles
- treatment period followed by recovery then another treatment period
usually 2-4 weekly depending on regimen
FEC
- fluorouracil, epirubicin, cyclophosphamide
What is the difference between solid tumours and haematological cancers?
solid tumours
- rarely affect blood counts unless bone marrow is involved
- have temporary decreases in blood count due to treatment
haematological malignancies
- affect blood counts
- already have low blood counts prior to treatment
= leukaemia, lymphoma, myeloma
What is neutropenic nadir? When does it occur?
neutropenia occurs after chemotherapy is given
- neutrophil levels reach a low point 7-10 days after treatment
- <0.5 x10^9 /L
neutropenic nadir is when neutrophils reach the ‘lowest point’
- at this point there is the highest risk of infection
once the count is recovered, then the next cycle of chemotherapy treatment can be given
What are the symptoms of neutropenic sepsis? When do they occur?
symptoms
- fever
= signs and symptoms may be reduced due to lack of an inflammatory reaction
risk of infection is great with a decline in neutrophil count and longer duration of neutropenia (>7 days)
occurs when neutrophil count is <0.5 x10^9 /L
What are the causative pathogens of neutropenic sepsis?
gram positive
- streptococcus
- staphylococcus
gram negative
- E.coli
- klebsiella spp
- pseudomonas aeruginoda
fungal
- candida
- aspergillus
What are the risk factors for neutropenic sepsis?
age >65 years
advanced disease
previous chemotherapy or radiotherapy
open wounds surgery
poor nutritional status
poor renal function
liver dysfunction
cardiovascular disease
HIV infection
What investigations can be done for neutropenic sepsis?
physical
- temperature, pulse, blood pressure, oxygen saturations, NEWS score
blood test
- full blood count, renal and liver function tests, lactate, CRP
blood cultures
- from line and peripheral vein
site of possible infection
urine sample
chest X-ray
What is the treatment for neutropenic sepsis?
first line
- piperacillin/tazobactam 4.5g IV QDS with amikacin 15mg/kg IV stat then adjust to renal function
mild penicillin allergy/high dose methotrexate
- ceftazidime 2g IV TDS with amikacin 15mg/kg IV stat then adjust to renal function
severe penicillin allergy
- teicoplanin 400mg BD 3 doses then OD, ciprofloxacin 400mg IV BD and amikacin 15mg/kg IV stat then adjust to renal function
What is the treatment for neutropenic sepsis?
first line
- piperacillin/tazobactam 4.5g IV QDS with amikacin 15mg/kg IV stat then adjust to renal function
mild penicillin allergy/high dose methotrexate
- ceftazidime 2g IV TDS with amikacin 15mg/kg IV stat then adjust to renal function
severe penicillin allergy
- teicoplanin 400mg BD 3 doses then OD, ciprofloxacin 400mg IV BD and amikacin 15mg/kg IV stat then adjust to renal function
What antibiotics should be used for neutropenic sepsis with
- MSSA
- MRSA
- Carbapenemase gram negative
MSSA - flucloxacillin
MRSA - vancomycin
Carbapenemase gram negative - colistin IV
What prophylactic antibiotics are used gram negative bacteria like pseudomonas aeruginosa?
use fluoroquinolones
- ciprofloxacin 500mg PO BD
- levofloxacin 500mg PO OD
What is filgrastim? What is it used for? When is it given?
contain recombinant G-CSF to stimulate the bone marrow to produce white blood cells
- used to prevent neutropenia in susceptible patients
= G-CSF is a type of growth factor that makes the bone marrow produce more white blood cells
given over or before the expected nadir period
- usually 5-9 days
5mcg/kg SC OD
- <80kg = 300mcg
- >80kg = 480mcg
What is haematopoiesis?
process by which the body produces blood cells and blood plasma
- erythrocytes, platelets, granulocytes, lymphocytes, and monocyte
= starts with a pluripotent stem cell
What is the main side effects of filgrastim? How is it managed?
What are precautions associated with filgrastim?
bone pain
- managed with paracetamol with/without NSAIDs
precautions
- pulmonary adverse effects
= cough, fever, dyspnoea
- capillary leak syndrome
= dyspnoea, hypoalbuminaemia, oedema, haemoconcentration (rise in RBCs) - glomerulonephritis
When should filgrastim be used?
if the risk of febrile neutropenia from chemotherapy regimen is 20%
- if 10-20% then consider patient risk factors before use
How should low platelet and erythrocyte count caused by chemotherapy be treated?
platelets
- rarely required unless platelet count is <20
- usually delay chemotherapy by a week and consider dose reduction
erythrocytes
- give blood to raise haemoglobin quickly
