Neutropenic Sepsis Flashcards
Neutropenic Sepsis
Defined as Neutrophil Count of:
- < 0.5x109 in patient having anti cancer treatment
- temp higher than 38ºC or
- other signs or symptoms clinically significant sepsis
Defined as Neutrophil Count of:
- < 0.5x109 in patient having anti cancer treatment
- temp higher than 38ºC or
- other signs or symptoms clinically significant sepsis
Neutropenic Sepsis
Prophylaxis
if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 109 as a consequence of their treatment they should be offered a fluoroquinolone
Neutropenic Sepsis
Management
(1)
- Antibiotics must be started immediately, do not wait for the WBC
- NICE recommend starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately
- many units add vancomycin if the patient has central venous access but NICE do not support this approach
- following this initial treatment patients are usually assessed by a specialist and risk-stratified to see if they may be able to have outpatient treatment
Neutropenic Sepsis
Management
(2)
- if patients are still febrile and unwell after 48 hours an alternative antibiotic such as meropenem is often prescribed +/- vancomycin
- if patients are not responding after 4-6 days the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT), rather than just starting therapy antifungal therapy blindly
- there may be a role for G-CSF in selected patients
(Granulocyte-colony stimulating factor (G-CSF or GCSF), also known as colony-stimulating factor 3 (CSF 3), is a glycoprotein that stimulates the bone marrow to produce granulocytes and stem cells and release them into the bloodstream)
Neutropenic Sepsis
Questions 1
Lucy is 45 year old lady who is currently being treated for metastatic breast cancer. She is having neo-adjuvant chemotherapy prior to a surgical resection. Her last chemotherapy was 7 days ago. She presents to you in your GP surgery with lethargy and myalgia. She has no cough, dysuria or rashes. Her observations today show: Temperature: 38.3 degrees celsius, blood pressure: 110/80 mmHg and heart rate of 110 bpm. What is the appropriate management?
- Prescribe co-amoxiclav and review in 1 day*
- Arrange urgent bloods, prescribe co-amoxiclav and review in 1 day*
- Advise to take paracetamol, arrange urgent bloods and review in 1 day*
Urgent admission to hospital
Dip urine and send mid-stream urine and prescribe trimethoprim
Rationale:
The correct answer is to arrange an urgent admission.
Lucy is at high risk of developing neutropenic sepsis, especially with the time frame described above following chemotherapy.
In addition her observational parameters are concerning as they suggest the onset of sepsis with a temperature above 38 degrees celsius and a pulse of 110 bpm.
The NICE guidelines (2012) state that patients who have suspected sepsis and are taking anticancer therapy should be referred for immediate assessment in hospital.
Given the main differential here is neutropenic sepsis the other options would not be appropriate in Lucy’s management.
Neutropenic Sepsis
Questions 2
A 45-year-old woman who is being treated for Hodgkin’s lymphoma with ABVD chemotherapy is reviewed on the haematology ward. She has been admitted by her GP with a fever of 38.9ºC. Her blood count from two days ago was as follows:
Blood pressure is 102/66 mmHg and the heart rate is 96/min. Respiratory examination is unremarkable. You insert an intravenous cannula and take bloods including cultures. What is the most appropriate next step in management?
Start intravenous ceftriaxone + amphotericin B
Await the repeat white blood cell count then phone the haematology consultant
Start intravenous piperacillin with tazobactam (Tazocin)
Start intravenous ceftriaxone + gentamicin
Start intravenous piperacillin with tazobactam (Tazocin) + G-CSF
Rationale:
This patient almost certainly meets the diagnostic criteria for neutropenic sepsis given the blood result from two days ago. Empirical antibiotics need to be started immediately - you should not wait for the repeat neutrophil count.
Tazocin is recommend as the first-line antibiotic by NICE. G-CSF is not used routinely in neutropenic sepsis.
Neutropenic Sepsis
Questions 3
You are a doctor working in the Emergency Department on Christmas Day. Your next patient is a 73-year-old female who presents with burning when passing urine. She has a past medical history of COPD and congestive cardiac failure. Seven days ago she completed a round of chemotherapy for breast cancer.
- Observations:
- Temperature 38.3ºC
- Heart rate 74/min
- Respiratory rate 22/min
- Blood pressure 134/86mmHg
- Oxygen saturations 91%
Examination is unremarkable except suprapubic tenderness and bilateral pitting oedema to the knees.
You are awaiting routine blood results.
What is the next stage of your immediate management?
- Bladder scan*
- Add a D-Dimer to the bloods*
- Begin immediate empirical antibiotic therapy before receiving blood results*
- Prescribe a five day course of nitrofurantoin 50mg QDS*
- Request urgent cardiology review*
Rationale:
- A marker of neutropenic sepsis includes a known cause of neutropenia and a temperature of > 38 degrees
- NICE guidelines for neutropenic sepsis (2016) state that neutropenic sepsis should be suspected in a person with a known cause for neutropenia (recent cancer treatment), presumed or confirmed infection, temperature >38ºC and respiratory rate >20 breaths per minute. Guidelines in the link below state it is important to not delay the administration of antibiotics whilst waiting for blood results. The choice of antibiotic used is dependent on local trust policy but usually involves piperacillin/tazobactam.
- As there is not a history of retention a bladder scan would not be required.
- A D-dimer would be raised in malignancy therefore is of little diagnostic value.
- A cardiology review would be indicated here though this would not be in the immediate management of the patient.
