What is the best course of action for a patient with a history of breast cancer presenting with ground glass opacities on imaging and suspected sepsis?

From the Guidelines

The best course of action for a patient with a history of breast cancer presenting with ground glass opacities on imaging and suspected sepsis is to initiate immediate sepsis management and thorough investigation of the pulmonary findings. This approach should include aggressive sepsis management with broad-spectrum antibiotics, such as piperacillin-tazobactam 4.5g IV every 6 hours plus vancomycin 15-20mg/kg IV every 8-12 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. Fluid resuscitation with crystalloids at 30ml/kg should be administered within the first 3 hours, and vasopressors should be used if needed to maintain mean arterial pressure above 65mmHg, as suggested by the guidelines 1. Blood cultures should be obtained before antibiotic administration, lactate levels should be measured, and vital signs should be monitored closely. Simultaneously, the ground glass opacities require thorough investigation, which may include a pulmonary consultation and possible bronchoscopy with bronchoalveolar lavage to obtain samples for microbiological and cytological examination. The patient's oncology history necessitates oncology consultation to review previous treatments and consider cancer-related complications, as emphasized in the management of sepsis and septic shock 1. Oxygen support should be provided as needed, and mechanical ventilation may be necessary if respiratory status deteriorates. This approach addresses both the immediate sepsis threat and the underlying cause of the pulmonary findings, which is crucial given the patient's cancer history that increases the risk for both infectious and malignant pulmonary complications. Key considerations in the management of sepsis include the prompt identification and control of the source of infection, as well as the implementation of appropriate antimicrobial therapy, as outlined in the Surviving Sepsis Campaign guidelines 1. The selection of optimal source control methods must weigh the benefits and risks of the specific intervention, and the least invasive effective option should be pursued, as recommended by the guidelines 1. Intravascular devices suspected to be a source of sepsis should be removed promptly after establishing another site for vascular access, as suggested by the guidelines 1.

Some key points to consider in the management of this patient include:

• Aggressive sepsis management with broad-spectrum antibiotics and fluid resuscitation
• Thorough investigation of the pulmonary findings, including pulmonary consultation and possible bronchoscopy with bronchoalveolar lavage
• Oncology consultation to review previous treatments and consider cancer-related complications
• Prompt identification and control of the source of infection
• Implementation of appropriate antimicrobial therapy
• Removal of intravascular devices suspected to be a source of sepsis
• Oxygen support and mechanical ventilation as needed. The patient's history of breast cancer and the presence of ground glass opacities on imaging increase the complexity of the case, and a multidisciplinary approach is necessary to ensure the best possible outcome. By following the Surviving Sepsis Campaign guidelines and considering the patient's unique history and presentation, healthcare providers can provide optimal care and improve outcomes for this patient.

From the Research

Sepsis Criteria and Breast Cancer History

• A patient with a history of breast cancer presenting with ground glass opacities on imaging and suspected sepsis requires careful evaluation and management 2, 3.
• Ground glass opacities can be a manifestation of various diseases, including lung metastasis from breast cancer, and a definitive diagnosis may require lung biopsy 2.
• The presence of ground glass opacities and suspected sepsis warrants a thorough investigation, including blood and urine cultures, to identify the underlying cause of infection 4.

Antibiotic Therapy for Sepsis

• The choice of antibiotic therapy for sepsis is crucial, and the combination of vancomycin and piperacillin/tazobactam is commonly used, but recent reports have raised concerns about nephrotoxicity 5.
• Alternative antibiotic choices, such as cefepime, may be considered, especially in patients with no clear indication for antianaerobic coverage 6.
• A study found that administration of piperacillin-tazobactam was associated with higher mortality and increased duration of organ dysfunction compared with cefepime in patients with suspected sepsis 6.

Diagnostic Approach

• The diagnostic approach for a patient with ground glass opacities and suspected sepsis should include a thorough medical history, physical examination, and imaging studies, such as high-resolution computed tomography (HRCT) 3.
• The role of the radiologist is evolving, and they should play a significant part in the clinical evaluation of a patient presenting with ground glass opacification 3.
• Critical features to evaluate in such cases include the duration of clinical symptoms, the presence or absence of lung fibrosis, the patient's history of smoking, and the distribution of the disease 3.