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Neutropenic sepsis

About

What is covered

This interactive flowchart covers preventing, identifying and managing neutropenic sepsis in people having anticancer 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).
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 interactive flowchart

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.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing, identifying and managing neutropenic sepsis in children, young people and adults in an interactive flowchart

What is covered

This interactive flowchart covers preventing, identifying and managing neutropenic sepsis in people having anticancer 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).
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 interactive flowchart

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.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Fungitell for antifungal treatment stratification (2017) NICE medtech innovation briefing 118

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

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
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
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: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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