Neutropenic Sepsis

Clare Dikken

Macmillan Senior Chemotherapy Nurse

Sussex Cancer Network

Aims and Objectives

• To understand the terminology around neutropenic sepsis (NS)

• To identify signs and symptoms associated with NS

• To have a better understanding patho-physiology around NS

• To articulate how a patient with NS should be managed initially

Treatment of cancer

• Escalating use of cytotoxic therapy

• Used on a wide range of tumour sites

• Greater use in palliative care

• Increase in the number of lines of treatment

• Drug developments: monoclonal antibodies, small molecules3

Side effects

• Chemotherapy affects actively dividing cells

• It is not specific to cancer cells

• Results in a wide range of side effects

• Some can be life threatening

• Neutropenic sepsis is a life threatening side effect of chemotherapy

The neutrophil and neutropenia

• First line defence against bacterial infection

• Neutropenia = abnormally low neutrophil count

• Associated with an increased risk of potentially life threatening infection

• In general this is considered as a neutrophil count of < 1.0

• Measured by the absolute neutrophil count

• The nadir = 7-14 days post chemo• Neutropenic sepsis

Sepsis

• Sepsis is the clinical syndrome from SIRS• Inflammatory reaction results from infection• Micro-organisms invade the blood and

release toxins• Decrease tissue oxygenation is an important

physiological factor• Septic shock

SIRS

• Signs and Symptoms– Hypothermia or fever – Shaking or chills– Tachycardia– Hypotension – Tachypnoea

Sepsis

• Sepsis is the clinical syndrome from SIRS• Inflammatory reaction results from infection• Micro-organisms invade the blood and

release toxins• Decrease tissue oxygenation is an important

physiological factor• Septic shock

Term Definition

Infection Localised presence of infection

Bacteraemia Presence of viable bacteria in the blood

Systemic inflammatory response syndrome (SIRS)

At lease two of the previously mentioned conditions in response to clinical insult

Sepsis Presence of two or more SIRS criteria with infection

Severe Sepsis Sepsis with one or more signs of organ dysfunction

Septic Shock Sepsis with hypotension unresponsive to fluids

Bone et al 1992

Risk factors

Increased risk of septic shock

Neutropenia Age >65 or<1 yr

Corticosteroids and immunosuppressive therapy

Malignancy

Splenectomy

Chemotherapy

RadiotherapyMalnutrition

Hospitalisation

Antibiotic use

Breakdown of skin/mucous membrane

Invasive procedures

SOURCE OF INFECTION

Release of endo/exo toxins

IMMUNE RESPONSE

Recruitment of plasma cells; neutrophils,

macrophages, monocytes

Release of cytokines, proand anti-

inflammatory response mediators:e.g.

interleukins, nitric oxide, complement, platelet activating

factors, protaglandins etc

EFFECT ON BODY

Vasodilatation, endothelial inflammation,

increased vascular permeability,

decreased arterial and venous tone,

hypotension, myocardial depression

END POINT

End organ hypo-perfusion,

ischemia and cell death

Signs and Symptoms

Neutropenic sepsis

• Incidence: depends on drug regime, patient and duration of neutropenia

• Deaths are still occurring • Preventable deaths• Reason for deaths:

delay in getting into acute hospitaldelay in diagnosisdelay to first dose of antibioticneutropenic policy not being followed

• Many health professionals have never received any training or education on neutropenic sepsis

What can you do?

• Recognise at risk patients

• Recognise early and late presenting signs and symptoms

• Rapid referral to Acute services

• Use HEAT as a trigger

Patients at Risk

• Post chemotherapy 7-14 days• Haematology patients• Heavily pre-treated• Prior history of neutropenic sepsis• Breaches to the skin/mucous membranes• Co-morbid conditions e.g.advanced cancer• Poor general health • Elderly

What can you do?

• Recognise at risk patients• Recognise early and late presenting signs and

symptoms• Rapid referral to Acute services• Rapid diagnosis: FBC, blood cultures• Early intervention with appropriate treatment• Monitoring• Reporting

The HEAT Trigger

• H- History

• E- Examine

• A- Action

• T- Treat

Take home message

Patient on chemotherapy? Be suspicious

ACT FAST TO PREVENT DEATH