Neutropenic Sepsis

1. Neutropenic Sepsis Clare Dikken Macmillan Senior Chemotherapy Nurse Sussex Cancer Network

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. Bone et al 1992

10. Risk factors Breakdown of skin/mucous membrane Age >65 or<1 yr Neutropenia Corticosteroids and immunosuppressive therapy Antibiotic use Increased risk of septic shock Invasive procedures Malignancy Hospitalisation Splenectomy Malnutrition Radiotherapy Chemotherapy

11. 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 mediators:e.g. interleukins, nitric oxide, complement, platelet activating factors, protaglandins etc END POINT End organ hypo-perfusion, ischemia and cell death

12. Signs and Symptoms

13. 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

14. 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

15. 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

16. 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

17. The HEAT Trigger • H- History • E- Examine • A- Action • T- Treat

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