Neutropenic Sepsis

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Neutropenic Sepsis

• Clare Dikken
• Macmillan Senior Chemotherapy Nurse
• Sussex Cancer Network

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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

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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

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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

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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 lt 1.0
• Measured by the absolute neutrophil count
• The nadir 7-14 days post chemo
• Neutropenic sepsis

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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

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SIRS

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

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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

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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
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Risk factors
Breakdown of skin/mucous membrane
Age gt65 orlt1 yr
Neutropenia
Corticosteroids and immunosuppressive therapy
Antibiotic use
Increased risk of septic shock
Invasive procedures
Malignancy
Hospitalisation
Splenectomy
Radiotherapy
Malnutrition
Chemotherapy
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SOURCE OF INFECTION
IMMUNE RESPONSE
EFFECT ON BODY
Vasodilatation, endothelial inflammation,
increased vascular permeability, decreased
arterial and venous tone, hypotension,
myocardial depression
Recruitment of plasma cells neutrophils,
macrophages, monocytes
Release of endo/exo toxins
Release of cytokines, proand anti-inflammatory
response mediatorse.g. interleukins, nitric
oxide, complement, platelet activating factors,
protaglandins etc
END POINT
End organ hypo-perfusion, ischemia and cell death
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Signs and Symptoms
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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

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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

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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

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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

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The HEAT Trigger

• H- History
• E- Examine
• A- Action
• T- Treat

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Take home message
Patient on chemotherapy? Be suspicious ACT FAST
TO PREVENT DEATH
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