From the Guidelines
Neutropenic sepsis management involves prompt empirical antibiotic therapy, with the goal of reducing morbidity and mortality in patients with chemotherapy-induced neutropenia.
Management Options
- Empirical antibiotic therapy: should be initiated urgently (within 2 hours) after presentation, as infection may progress rapidly in these patients 1.
- Antibacterial prophylaxis: fluoroquinolones, such as levofloxacin, are commonly used in adults with chemotherapy-induced neutropenia to reduce the risk of severe bacterial infections 1.
- Antifungal prophylaxis: may be considered in patients with prolonged neutropenia, as fungi are rarely identified as the cause of first fever early in the course of neutropenia, but may cause life-threatening infections after the first week of empirical antibiotic therapy 1.
- White blood cell (WBC) growth factors: such as hematopoietic colony-stimulating factors (CSFs), may be used to reduce the duration and severity of neutropenia and the risk of febrile neutropenia 1.
Key Considerations
- Prompt initiation of therapy: is crucial in patients with neutropenic sepsis, as delays in treatment can lead to increased morbidity and mortality 1.
- Local epidemiologic data: should be taken into account when selecting empirical antibiotic therapy, as the prevalence of resistant organisms may vary by region 1.
- Involvement of an infectious diseases specialist: is recommended for the management of neutropenic sepsis, as these patients often require complex and individualized care 1.
- Antimicrobial stewardship programs: should be in place at facilities where patients with cancer are routinely treated, to ensure appropriate and judicious antimicrobial use 1.
From the Research
Management Options for Neutropenic Sepsis
The management of neutropenic sepsis in patients undergoing chemotherapy involves prompt and effective treatment to prevent mortality. The following options are considered:
- Hospitalization for intravenous empiric antibiotic therapy is recommended for high-risk patients, such as those with clinical instability or a Multinational Association of Supportive Care in Cancer score of < 21 2.
- Monotherapy with an anti-pseudomonal ß-lactam agent is recommended for empiric antibiotic therapy 2.
- Piperacillin-tazobactam or carbapenem may be considered as empiric antibiotics if multidrug-resistant (MDR) bacteria are suspected to be causative agents 2.
- A third-generation cephalosporin with/without an aminoglycoside is commonly used as empirical treatment, with a resolution of fever in 75% of patients 3.
- Bacteriologic cultures are useful in guiding the change of antibiotics, especially in patients with positive cultures 3.
- Awareness of the presenting characteristics and prompt management of sepsis is crucial to reduce mortality in neutropenic cancer patients 4.
- Ambulatory management may be considered for low-risk neutropenic sepsis patients, with a focus on integrated acute cancer care 5.
- Improving door-to-needle times for patients with suspected neutropenic sepsis is essential, and can be achieved through collaborative projects between acute oncology services and emergency departments 6.
Antibiotic Resistance and Microbial Etiology
- Gram-negative bacteria are the predominant causative organisms in neutropenic septic shock, with 77.1% of cases attributed to these bacteria 2.
- MDR bacteria are prevalent in patients with chemotherapy-induced neutropenic septic shock, with 30.3% of microorganisms being MDR 2.
- Extended-spectrum ß-lactamase-producing Escherichia coli is the most common MDR bacteria, accounting for 50% of cases 2.
- The gastrointestinal tract and unknown sites are the most commonly affected areas in patients with MDR bacterial infections 2.