1. Neutropenic sepsis Dr Christopher Dalley Consultant Haematologist

2. Causes of neutropenia  Chemotherapy/other drugs/radiotherapy  Haematologic cancer  Aplastic anaemia  Connective tissue disorders

3. How do you grade neutropenia?  Mild  Neutrophils 1.0-1.5x10 9 /L  Moderate  Neutrophils 0.5-1.0x10 9 /L  Severe  Neutrophils <0.5x10 9 /L

4. Important Point! “Risk of infection increases with duration and severity of neutropenia”

5. Neutropenic sepsis: Background  Potentially fatal complication of anticancer therapy  Most cases present in community  Mortality ranges from 2-20%  Should be considered as medical/haematologic emergency

6. How do we reduce the risk of neutropenic sepsis? Patient & Carer  Written information and oral information  Neutropenic sepsis  Who to contact if unwell- 24hr helpline  How and when to seek emergency care  Prophylactic antibiotic  Fluroquinolone to cover periods of severe neutropenia

7. How do we reduce the risk of neutropenic sepsis? Secondary and tertiary care  Suspect neutropenic sepsis in pts on chemotherapy or with haematologic cancer who are unwell  Review patients with febrile neutropenia promptly and prioritise their care

8. Case based discussion  Male aged 67 yrs  Completed oral chemo for chronic leukaemia 10 days ago  Woke up this morning with aches in muscles  Took his temp at home 37.8 o C,  Advised to go to A&E by haematology day ward nurse

9. Managing neutropenic sepsis in secondary and tertiary care Emergency treatment and assessment  Treat suspected neutropenic sepsis as a medical emergency  Offer empiric antibiotics therapy immediately  Do not assume, check it has been given!  Include clinical assessment of patient  History and examination  Are they hypoxic?  What’s the temperature?  What is the Bp?  Are they shut down?  Are they passing urine?  Inx FBC/Cultures/U&E/Coag/Lactate/CXR

10. Antibiotics  Commence iv Tazocin 4.5g 6hrly  Do ensure the first dose is given within the 1 st hr of presentation  Add in gentamicin 5mg/Kg (max 400mg) if hypotensive  Add in Teicoplanin 400mg bd for 3 doses then od if line sepsis thought likely

11. Antibiotics  If penicillin alllergic  Don’t use Tazocin,  Start iv Ceftazadime 2g tds

12. Antibiotics  If still febrile at 48hrs  Consider starting Teicoplanin to cover gram pos organisms if not already started  Consider starting iv Mereopenem 1g tds and stopping Taz  If febrile at 96 hrs  Start Voriconazole and book HRCT chest

13. Supportive care  IV fluids  Hypotension  Blood products  Keep platelets above 20x10 9 /L  Growth factor  G-CSF

14. Escalate!  Ask for Haematology/Oncology advice and review  Ask for Microbiology advice  Ask for early HDCU Outreach review

15. Summary  Neutropenic sepsis is a medical emergency  Always take febrile neutropenia seriously  Start antibiotics quickly, and continue to prioritise their care and continue to review