1. Neutropenic Sepsis
MICHAEL – JOHN DEVLIN (CT2)

2. Aims
 Definitions
 Evaluation
 Treatment
 Microbiology
 G-CSF

3. Neutropenia
 ANC < 1 X 109L regardless of overall WCC
 Aplastic anaemia, haematological malignancies,
radiation exposure, heredity or AI conditions
 Cytotoxic Chemotherapy
 Systemic infection is potentially life threatening
and timely intervention is life saving

4. Definitions
 Systemic Inflammatory Response Syndrome (SIRS) : The systemic
inflammatory response to a variety of severe clinical insults (often, but not
necessarily infection). The response is manifested by two or more of the
following conditions
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Temperature > 38 or < 36
Heart Rate > 90 beats/minute
Respiratory Rate > 20 breaths/minute or PaCO2< 4.3 KPa
White Cell Count > 12x109/L or < 4x109/L
 Sepsis : The systemic response to infection.
 Severe Sepsis : Sepsis associated with organ dysfunction, hypoperfusion, or
hypotension
 Septic Shock: Severe sepsis with hypotension despite adequate fluid
resuscitation which requires inotropes or vasopressors.

5. Evaluation of Neutropenic Patient
 History
 Examination
 Absence of neutrophils means signs of inflammation can be
extremely subtle
 Temp not always present
 BP <100, HR >90, RR>20
 Labs
 Cultures
 Blood (peripheral and central), urine, sputum, site swabs, stool
 Imaging
 CXR vs HRCT

6. “Door to Needle Time”
60 MINUTES

7. Infection in Neutropenic Patients
 10-25 % documented bactraemia
 Clinical infections found in 30%
 Historically gram-negative but now rise in gram-
positive
 Fungi and viruses in high risk patients

8. Antibiotics
 First line
Tazocin and Gentamicin +/- teicoplanin
 Ciprofloxacin, Gentamicin and teicioplanin
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 Second line
48 hours unresponsive fever or deterioration
 Meropenum, Amikacin +/- teicoplanin
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11. G-CSF
 In Neutropenic fever
 Controversial
 Decreases length of neutropenia, fever and admission
 Increases bone, joint pain and arthralgia
 No survival benefit
 ESMO
 High risk for infection associated complications
 Predictors of poor clinical outcome

12. High Risk Patients
 Prolonged neutropenia (>10 days)
 Profound neutropenia (ANC <0.01)
 Aged >65
 Uncontrolled Primary Disease
 Pneumonia
 Hypotenion
 Multiorgan dysfunction
 Invasive fungal infections
 Hospitalized at time fever developed

13. Case 1
 28 year old AML 10 days post bone marrow
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transplant
Temp 38
RR 14, Sat 98%, HR 65, BP 120/85
Feels well
Examines normally
Bloods and cultured
Tazocin and Gentamycin

14.  Confirmed pancytopenia ANC 0
 Sudden and dramatic deterioration;
 Drowsy
 RR 30, HR 140, BP 80/40 – catheterized with no output
 Temp 38
 ABG severe acidosis
 ABCDE
 ICU assessment – for escalation
 Arrested
 Confirmed dead 2 hours after first temp spike

15. Case 2
 60 year old with breast cancer
 C2 D10 FEC-D
 “Just not right” and felt hot at home
 Diarrhoea for 1/7 and a sore mouth
 RR20, HR100, BP 110 systolic, temp 37.8
 Examination mild abdominal distension and
tenderness RIF and oral mucositis

16.  FBP, ONC, CRP, COAG, Blood Cultures, Stool
 CXR and AXR
 Tazocin
 Nurse concerned that BP has dropped with systolic
reading 90 and temp has shot up to 39
 Abdominal pain is getting a bit worse and on reexamination some guarding
 Confirmed neutropenia
 Gentamycin and surgical review

18. Typhlitis
 Necrotizing entrocolitis of the caecum
 30% fatal
 Neutropenia
 Children and AML
 Presentation
 RIF pain, diarrhoea, pyrexia
 Investigation
 AXR, USS or CT
 Management
 IVF, IV antibiotics and may require surgery
 Necrosis, perforation and septicaemia

19. Summary
Medical Emergency
 Consider in anyone within 6 weeks of chemotherapy
 Treat first and confirm later
 Tazocin and Gent
 Cipro, Gent and Teic
 Examination and re-examination
 G-CSF where appropriate

20. Sources
 Oxford Handbook of Emergencies in Oncology:
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Martin Scott-Brown et al
Oxford Handbook of Oncology 2nd Edition: Jim
Cassidy et al
NICaN guidelines on Neutropenic Sepsis
www.cancerni.net
NICE guidelines on Neutropenic Sepsis
Uptodate.com