21st June 2023

Neutropenic sepsis

Diagnosis

Neutropenic sepsis is diagnosed in patients who have a neutrophil count of ≤ 0.5 x 10⁹/litre with a temperature ≥38.0℃ (or <36.0℃) and/or with features suggestive of sepsis. It is a potentially fatal complication of systemic anticancer therapy or for those living with bone marrow failure. It should be suspected in patients with the aforementioned signs and symptoms in those who have undergone chemotherapy within the preceding 4-30 days. However, the risk is highest between days 7-12 after chemotherapy.

Historical mortality rates of between 2-21% resulted in the ‘National Confidential Inquiry into Patient Outcome and Death – Systemic anticancer therapy: For better or worse?’ report in 2008. This, and subsequent reports, highlighted deficiencies in the provision of care for patients undergoing chemotherapy in the management of neutropenic sepsis, resulting in avoidable deaths. This led to the provision of 24-hour contact numbers for patients to report symptoms and for the provision of emergency empirical antibiotic treatment.

Management

Patients suspected of neutropenic sepsis should be managed with intravenous broad-spectrum antibiotics within 1 hour of presentation (the mantra of ‘door to needle time’ of less than 1 hour). Typically this should be a beta-lactam based antibiotic such as piperacillin + tazobactam (Tazocin). Bloods should be taken including FBC, U&Es, CRP, lactate, and blood cultures. A full clinical examination, observations, and appropriate septic screen investigations (i.e. chest x-ray, urine cultures) should be undertaken. Note that patients with septic shock or signs of severe sepsis should be aggressively managed with intravenous fluids and with early discussion with ITU.

The MASCC (Multinational Association for Supportive Care in Cancer) score can be employed as a triaging tool to ascertain overall risk. It incorporates information on the underlying cancer, patient factors (age, comorbidities) and clinical factors (hypotension, hypovolaemia). Those at ‘low-risk’ may be managed with oral antibiotics in the community, provided they have adequate support networks.

The use of granulocyte-colony stimulating factor (G-CSF) may be employed prophylactically within a chemotherapy regimen if there is an associated significant risk of neutropenia. It can also be considered in patients with prolonged or profound neutropenia.