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Neutropenic sepsis overview

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Neutropenic sepsis HAI

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

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 neutropenic sepsis in people having anticancer treatment.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

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

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.

Sources

The NICE guidance that was used to create the pathway.
Neutropenic sepsis. NICE clinical guideline 151 (2012)

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

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Pathway information

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 neutropenic sepsis in people having anticancer treatment.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

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

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: January 2014

© NICE 2014

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