Neutropenic Sepsis

Question 1

what is neutropenic sepsis?

Answer 1

a neutrophil count of 0.5 × 109 per litre or lower, plus one of the following:
- temperature ≥ 38°C
- other signs or symptoms consistent with significant sepsis

Question 2

how does recent chemotherapy contribute to neutropenic sepsis in cancer patients?

Answer 2

chemotherapy (e.g. most commonly within 7–10 days) causes neutropenia through bone marrow suppression, which is the major cause of neutropenic sepsis in cancer patients

Question 3

what are the other causes of neutropenia?

Answer 3

• malignant bone marrow infiltration
• extensive radiotherapy
• bone marrow failure secondary to non-malignant disease (e.g. aplastic anaemia)
• hypersplenism
• megaloblastic anaemia
• drug-induced (e.g. clozapine)

Question 4

what are the risk factors for developing neutropenic sepsis?

Answer 4

• > 60
• advanced malignancy
• mucositis (e.g. chemotherapy can induce mucosal damage and allow bacterial translocation)
• poor performance status
• significant co-morbidities
• indwelling central venous catheters
• corticosteroids
• prolonged hospital admission
• severe or prolonged neutropenia

Question 5

what system is used to grade the severity of neutropenia?

Answer 5

the common terminology criteria for adverse events (CTCAE)

Question 6

what are the non-specific symptoms of neutropenic sepsis?

Answer 6

• fatigue
• warm/cold
• rigors
• sweaty/clammy
• palpitations
• dizziness
• confusion/disorientation

Question 7

what symptoms of neutropenic sepsis reflect a specific infective source?

Answer 7

• chest (e.g. SOB, cough, chest pain, sore throat)
• urine (e.g. dysuria, frequency, urgency)
• skin (e.g. rashes, blisters, pain)
• gastrointestinal (e.g. diarrhoea, nausea, vomiting, rectal bleeding, abdominal pain, sore mouth)
• indwelling line (e.g. pain around the line or rigors after use of the line)

Question 8

what might the findings on examination of neutropenic sepsis be?

Answer 8

• haemodynamic instability (e.g. hypotension, tachycardia, tachypnoea, hypoxia)
• fever
• oliguria
• altered consciousness level or confusion
• mottled/ashen appearance

Question 9

what might the findings on examination specific to the infective source of neutropenic sepsis be?

Answer 9

• chest (e.g. increased work of breathing, crepitations, dullness to percussion, reduced air entry)
• urine (e.g. suprapubic or flank pain, cloudy urine in catheter bag)
• skin (e.g. rashes, blistering, tenderness)
• gastrointestinal (e.g. abdominal tenderness, dehydration, oral mucositis, jaundice)
• indwelling line (e.g. surrounding erythema, tenderness on palpation, pain or rigors on flushing)

Question 10

what are the bedside investigations for neutropenic sepsis?

Answer 10

• urinalysis
• ECG
• CBG

Question 11

what are the laboratory investigations for neutropenic sepsis?

Answer 11

• FBC
• U&Es
• LFTs
• CRP
• coagulation
• serum lactate
• G&S
• blood cultures (e.g. at least two sets from a peripheral vein plus a set from an indwelling line if present)
• ABG
• microbiological cultures (e.g. wound, urine, stool, sputum, line tip)
• ? viral respiratory swab

Question 12

what is the recommended initial management for patients with suspected or confirmed neutropenic sepsis upon arrival at the hospital?

Answer 12

• patients with suspected or confirmed neutropenic sepsis should receive empirical antibiotic therapy within one hour of arrival at hospital
• antibiotic therapy must not be delayed to wait for confirmation of neutropenia
• the sepsis six care bundle should be completed

Question 13

what is the recommended empirical antibiotic therapy for neutropenic sepsis?

Answer 13

• 1st-line: IV piperacillin with tazobactam (e.g. tazocin) +/- gentamicin
• 2nd-line: *IV meropenem
• additional anti-microbial cover (e.g. teicoplanin) for gram-positive organisms may be required for patients with indwelling central venous catheters
• anti-fungal treatment may be considered when the fever persists beyond 4 – 6 days

Question 14

what is the role of recombinant granulocyte-colony stimulating factor (G-CSF) in neutropenic sepsis?

Answer 14

• may be used for both prophylaxis and treatment of neutropenia to reduce the risk of neutropenic sepsis
• works by stimulating the bone marrow to produce neutrophils

Question 15

what are the long-term complications of neutropenic sepsis?

Answer 15

• single/multi-organ failure (e.g. ARDS)
• VTE (e.g. PE)
• DIC
• opportunistic/hospital-acquired infections
• delirium