Neutropenic sepsis is a potentially life-threatening complication of neutropenia (low neutrophil count). There are multiple possible causes of neutropenia such as cytotoxic chemotherapy and other immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders such as aplastic anaemia and myelodysplastic syndromes, and nutritional deficiencies. Mortality rates as high as 20% have been reported in adults.
Neutropenic sepsis can be diagnosed in patients having anticancer treatment, whose neutrophil count is 0.5 x 109 per litre or lower and who have either:
- A temperature higher than 38°C, or;
- Other signs or symptoms consistent with clinically significant sepsis
Reducing the risk of septic complications of anticancer treatment
Cancer treatment therapies suppress the ability of bone marrow to respond to infection and are one of the leading causes of neutropenic sepsis. This occurs most commonly with systemic chemotherapy but can also occur secondary to radiotherapy.
For this reason, all patients receiving anticancer therapies should receive clear written and oral information about this both before starting and throughout their anticancer treatment. This advice should include clear information about:
- Neutropenic sepsis and the warning signs and symptoms
- How and when to contact 24-hour specialist oncology advice
- How and when to seek emergency care.
The current NICE guidelines also advise that all adult patients with acute leukaemia, stem cell transplants or solid tumours, in whom significant neutropenia is an anticipated consequence of chemotherapy, should be offered prophylaxis with a fluoroquinolone (e.g. ciprofloxacin 500 mg PO BD) during the expected period of neutropenia.
Managing suspected neutropenic sepsis in primary care
Any person with suspected neutropenic sepsis should have an immediate hospital assessment in secondary or tertiary care arranged urgently.
The current NICE guidelines advise that:
- If the person is critically unwell, pre-alert secondary care about suspected neutropenic sepsis and arrange emergency transfer to hospital (usually by 999 ambulance).
- If the person is clinically stable, arrange emergency transfer to the local oncology or haematology unit, or medical assessment unit, using clinical judgement depending on local referral pathways. If there is any uncertainty, liaise with the person’s specialist team.
Managing suspected neutropenic sepsis in secondary or tertiary care
Specialist assessment and management in an acute hospital setting involve implementing the UK Sepsis Trust ‘Sepsis Six’ bundle within the first hour following recognition of sepsis.
The current NICE guidelines recommend that monotherapy with piperacillin with tazobactam (Tazocin 4.5 g IV) is used as initial empiric antibiotic therapy for patients with suspected neutropenic sepsis. Do not offer an aminoglycoside, either as monotherapy or in dual therapy, for the initial empiric treatment of suspected neutropenic sepsis unless there are patient-specific or local microbiological indications.
The MASCC Risk Index Score
The MASCC Risk Index Score (Multinational Association of Supportive Care in Cancer Risk Index Score) is an internationally validated scoring system that identifies low-risk patients with neutropenic sepsis that can potentially be treated as an outpatient with early antibiotics.
The MASCC Risk Index Score characteristics are as follows:
- Burden of febrile neutropenia with no or mild symptoms (5 points)
- No hypotension (SBP > 90 mmHg) (5 points)
- No chronic obstructive pulmonary disease (4 points)
- Solid tumour or haematological malignancy with no previous fungal infection (4 points)
- No dehydration requiring parental fluids (3 points)
- Burden of febrile neutropenia with moderate symptoms (3 points)
- Outpatient setting at onset of fever (3 points)
- Age <60 years (2 points)
A score of ≥21 is considered low risk and a score of <21 as high risk (positive predictive value of 91%, specificity of 68%, and sensitivity of 71%).
Identifying Patients at Low Risk for FN Complications: Development and Validation of the MASCC Risk Index Score
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Thank you to the joint editorial team of www.frcemexamprep.co.uk for this ‘Exam Tips’ blog post.