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Neutropenic sepsis overview

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Neutropenic sepsis

About

What is covered

This pathway covers the prevention, identification and management of neutropenic sepsis in children, young people and adults having anticancer treatment.
Neutropenic sepsis is a potentially fatal complication of anticancer treatment. Systemic therapies to treat cancer can suppress the ability of bone marrow to respond to infection. This is particularly the case with chemotherapy, although radiotherapy can also cause such suppression. Reported mortality rates from neutropenic sepsis in adults range from 2–21%. Chemotherapy is most commonly given in a day-case or outpatient setting so most episodes of obvious sepsis, and fever in a person with potential sepsis, present in the community. People having chemotherapy and their carers need to be told about the risk of neutropenic sepsis and the warning signs and symptoms. Neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment.

Advice from the Health Protection Agency

The Health Protection Agency has provided the following advice about NICE's recommendation on fluoroquinolone prophylaxis (see reduce the risk of septic complications of anticancer treatment in this pathway).
Fluoroquinolone prophylaxis is advocated as beneficial for some patients with neutropenia (see Antibiotic prophylaxis in neutropenic patients: new evidence, practical decisions). However, it raises 2 concerns:
  • fluoroquinolone prophylaxis can contribute to selection of resistance, particularly in Enterobacteriaceae
  • fluoroquinolones are associated with the selection of Clostridium difficile.
Attention should be paid to both risks.
Colonisation with resistant Enterobacteriaceae should be examined at induction of neutropenia and weekly thereafter until prophylaxis is stopped. The easiest method is to plate a rectal swab, or faeces, onto MacConkey agar, and to place a 1 mg (that is, standard) ciprofloxacin disc on the first series of streaks after the inoculum pool. After incubation the plate should be examined for bacterial colonies within the inhibition zone. If growth is found, the bacteria should be identified and their antibiograms determined, since many fluoroquinolone-resistant isolates are resistant to multiple other agents. The results should inform initial empiric therapy if the patient experiences a subsequent febrile episode. Time trends in resistance should be monitored, both in individual patients and within units.
Advice on the diagnosis of Clostridium difficile-related disease is provided in Updated guidance on the diagnosis and reporting of Clostridium difficile. This advice should be followed for patients with symptoms of diarrhoea.

Updates

Updates to this pathway

9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to emergency assessment and treatment.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to emergency treatment and assessment.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
8 April 2015 Minor maintenance update.
29 August 2014 Minor maintenance update.
2 January 2014 Minor maintenance update.
13 September 2013 Minor maintenance update.
3 May 2013 Minor maintenance updates.
21 September 2012 Podcast added to reduce the risk of septic complications of anticancer treatment in this pathway.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Prevention and management of neutropenic sepsis in cancer patients

What is covered

This pathway covers the prevention, identification and management of neutropenic sepsis in children, young people and adults having anticancer treatment.
Neutropenic sepsis is a potentially fatal complication of anticancer treatment. Systemic therapies to treat cancer can suppress the ability of bone marrow to respond to infection. This is particularly the case with chemotherapy, although radiotherapy can also cause such suppression. Reported mortality rates from neutropenic sepsis in adults range from 2–21%. Chemotherapy is most commonly given in a day-case or outpatient setting so most episodes of obvious sepsis, and fever in a person with potential sepsis, present in the community. People having chemotherapy and their carers need to be told about the risk of neutropenic sepsis and the warning signs and symptoms. Neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment.

Advice from the Health Protection Agency

The Health Protection Agency has provided the following advice about NICE's recommendation on fluoroquinolone prophylaxis (see reduce the risk of septic complications of anticancer treatment in this pathway).
Fluoroquinolone prophylaxis is advocated as beneficial for some patients with neutropenia (see Antibiotic prophylaxis in neutropenic patients: new evidence, practical decisions). However, it raises 2 concerns:
  • fluoroquinolone prophylaxis can contribute to selection of resistance, particularly in Enterobacteriaceae
  • fluoroquinolones are associated with the selection of Clostridium difficile.
Attention should be paid to both risks.
Colonisation with resistant Enterobacteriaceae should be examined at induction of neutropenia and weekly thereafter until prophylaxis is stopped. The easiest method is to plate a rectal swab, or faeces, onto MacConkey agar, and to place a 1 mg (that is, standard) ciprofloxacin disc on the first series of streaks after the inoculum pool. After incubation the plate should be examined for bacterial colonies within the inhibition zone. If growth is found, the bacteria should be identified and their antibiograms determined, since many fluoroquinolone-resistant isolates are resistant to multiple other agents. The results should inform initial empiric therapy if the patient experiences a subsequent febrile episode. Time trends in resistance should be monitored, both in individual patients and within units.
Advice on the diagnosis of Clostridium difficile-related disease is provided in Updated guidance on the diagnosis and reporting of Clostridium difficile. This advice should be followed for patients with symptoms of diarrhoea.

Updates

Updates to this pathway

9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to emergency assessment and treatment.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to emergency treatment and assessment.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
8 April 2015 Minor maintenance update.
29 August 2014 Minor maintenance update.
2 January 2014 Minor maintenance update.
13 September 2013 Minor maintenance update.
3 May 2013 Minor maintenance updates.
21 September 2012 Podcast added to reduce the risk of septic complications of anticancer treatment in this pathway.

Sources

NICE guidance and other sources used to create this pathway.
Neutropenic sepsis (2012) NICE guideline CG151

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
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Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Treatment that is given with the intent to reduce the level of cancer cells in a patient. It includes, but is not limited to, chemotherapy and radiotherapy
An action undertaken prior to determination of the underlying cause of a problem
An antibiotic given to a person before a specific microorganism or source of the potential infection is known. It is usually a broad-spectrum antibiotic and the treatment may change if the microorganism or source is confirmed
Antibiotics given to a person before a specific microorganism or source of the potential infection is known. They are usually broad-spectrum antibiotics and the treatment may change if the microorganism or source is confirmed
Granulocyte-colony stimulating factor. A type of protein that stimulates the bone marrow to make white blood cells (granulocytes)

Paths in this pathway

Pathway created: September 2012 Last updated: February 2016

© NICE 2016

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