Neutropenic Sepsis

NEUTROPENIC SEPSIS SUSPECTED - Requires URGENT SENIOR medical assessment.

See Department of Cancer Services Systemic Anti-Cancer Therapy (SACT): Guidelines for the Treatment of Neutropenic Sepsis in Adult Patients for more background and management information (intranet access required).

Definition of Neutropenic Sepsis - Neutrophil count < 0.5 x 109/L with other features of possible sepsis i.e. SIRS or high index of clinical suspicion.  Patients on chemotherapy or with neutropenia with or without fever are at risk of serious complications. These patients are at risk of serious, potentially fatal infections

First Line Investigations

  • FBC, Coag, U&E, LFT, Glucose,
  • Ca2+, PO4-, Mg2+, Lactate, CRP
  • Blood Cultures x 2 - peripheral plus CVC (all lumens). If no CVC then 2 sets (separate venepuncture).

Other Investigations

  • MSU
  • Chest X-ray
  • Throat & Nasal Swabs
  • Swabs CVC exit/skin lesions
  • Stool Culture/C. diff (if appropriate).

First Hour Management – INITIATE HIGHLAND SEPSIS RECORD Initial Bundle

If positive culture results are available, commence antibiotic regimen to cover known pathogens

Assess risk. High risk patients are those with septic shock or NEWS of 7 or above plus all patients with acute leukaemia or allogeneic transplant

For Haematology/Oncology patients, as soon as treatment is initiated, contact patient’s Consultant at Raigmore Hospital if during working hours.  If admitted out-of-hours and the patient is clinically stable this can be done the following morning.  

On-call Consultant Haematologist or Oncologist can be contacted through Raigmore switchboard if necessary.  Contact should be clearly documented in the medical notes.

Avoid fluoroquinolone if patient has received prophylaxis with ciprofloxacin

Duration – depends on diagnosis.  Seek advice from Haematology or Oncology Consultant

For glossary of terms see Glossary

Drug details

Initial Therapy (Day 0)

IV piperacillin/tazobactam 4.5g every 6 hours (3 hour infusion time per dose if in critical care)

In penicillin allergy

IV aztreonam 2g every 6 hours
PLUS
IV vancomycin - refer to NHS Highland vancomycin dosing guidelines

If patient has received or is receiving cisplatin, discuss with Oncology/Haematology/Microbiology Consultant for alternative to gentamicin or vancomycin (risk of nephrotoxicity). 

If high risk 

ADD IV gentamicin - refer to NHS Highland gentamicin dosing guidelines. High risk are patients with septic shock or NEWS of 7 or above plus all patients with acute leukaemia or allogeneic transplant

Maximum gentamicin duration without review is 72 hours

If patient has received or is receiving cisplatin, discuss with Oncology/Haematology/Microbiology Consultant for alternative to gentamicin or vancomycin (risk of nephrotoxicity). Please note treatment with gentamicin should be limited to minimise toxicity.

If MRSA is known or suspected, suspected central line infection or signs of skin/soft tissue infection

ADD IV teicoplanin or vancomycin – refer to NHS Highland vancomycin or NHS Highland teicoplanin dosing guidelines.

If patient has received or is receiving cisplatin, discuss with Oncology/Haematology/Microbiology Consultant for alternative to gentamicin or vancomycin (risk of nephrotoxicity). Please note treatment with gentamicin should be limited to minimise toxicity.

If CAP suspected and atypical cover required

ADD IV clarithromycin 500mg every 12 hours

Check for drug interactions with clarithromycin

If previous ESBL infection or known carrier

Use a meropenem 1g every 8 hours in place of piperacillin/tazobactam.

Check previous microbiology results for resistance information

If patient not improving or deteriorating after 48 to 72 hours (D2 to 3) and no positive culture – seek consultant approval

SWITCH to IV meropenem 1g every 8 hours

If patient still not improving or deteriorating after 48 to 72 hours (D5 to 6) and no positive culture - seek consultant approval

ADD IV caspofungin 70mg once daily

If patient weighs less than 80kg, give caspofungin 70mg stat then 50mg once daily thereafter

If fungal infection strongly suspected and patient not improving or is deteriorating after 72 hours (D8) of caspofungin

SWITCH to IV Ambisome® 3mg/kg once daily

After initial test dose, give full 3mg/kg dose (rounded to the nearest 50mg vial), do not increase dose gradually to 3mg/kg.

Last reviewed: 25 August 2022

Next review: 25 August 2025

Author(s): Antimicrobial Management Team

Version: 2

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Area Antimicrobial Pharmacist

Document Id: AMT176