Diagnosis, Treatment and Prevention of Neutropenic Sepsis

Creator: Dr. Smitha S. Dutt
Keywords: diagnosis of neutropenic sepsis, neutropenic sepsis treatment, fever, medical examination, physical history, bacterial infection, neutrophil count, blood culture, c-reactive protein, levels of liver and kidney proteins, serum lactate, serum bicarbonate, broad spectrum antibiotics, crystalloid fluids, antibiotic monotherapy, piperacillin, tazobactam, aminoglycoside therapy, gentamycin, chest x-ray, urine analysis, antifungal medications, liposomal amphotericin b, caspofungin, voriconazole

Author - Dr. Smitha S. Dutt, PhD

Medically Reviewed by Dr. Lakshmi Venkataraman, MD on Oct 14, 2020

How do you Diagnose Neutropenic Sepsis?

The diagnosis of neutropenic sepsis requires careful consideration of the symptoms to ensure the right treatment is provided. In certain cases, if cancer patients undergoing treatment do not show fever, they may not be suspected with neutropenic sepsis.

Hence, it is important to maintain a level of caution by examining even those cancer individuals undergoing treatment, who may be unwell in the absence of fever. This can especially happen in those who take steroids and so inflammation is diminished during chemotherapy. As a result, the usual symptoms of fever are not observed.

A full diagnostic examination should involve a complete medical examination and physical history.
Following this, the chest should be examined for circulation and breathing issues. The oropharynx, the internal regions (e.g. cardiac, brain, bones), and the skin must be checked for potential bacterial infections.
Samples from urine, from lesions on the skin, or from diarrhea should be examined for infection.
A digital rectal examination could cause potential infection to develop in the gut and is not generally advised.
In addition, the neutrophil count in the blood, blood culture, the level of C-reactive protein, and the levels of kidney and liver proteins should be assessed for sites of infection.
Elevated serum lactate levels and reduced serum bicarbonate levels are good indicators of a neutropenic sepsis infection.
Similarly, elevated C-reactive protein indicates a poor outcome of the infection. These indicators are useful in determining the antibiotic course.

How do you Treat Neutropenic Sepsis?

The recommendation to begin treatment for neutropenic sepsis is based on a falling neutrophil count that is less than 0.5 x 10⁹/litre and the presence of fever or temperatures that are higher than 38�C or lower than 36�C.

The first step is to intravenously treat the patient with broad spectrum antibiotics and crystalloid fluids within the first hour of detection. It should be noted that if treatment is delayed till the confirmation of neutropenia, then the individual is likely to die. Antibiotic monotherapy with piperacillin and tazobactam is recommended. Aminoglycoside therapy (e.g. gentamycin) with antibiotics is not generally favored.

Following the treatment, the patient's blood should be obtained from a central blood vessel as well as from peripheral sources. The blood samples can then be investigated for infection. Similarly, a chest x-ray and analysis of the urine sample (in children) are additional ways to confirm bacterial infection.

However, it has been noted that those individuals whose sepsis is resolved may still be susceptible to death in the ICU due to the failure of multiple organs, such as hepatic, respiratory, renal, or circulatory. Sometimes, they contract a secondary bacterial infection due to the organ failure.

The patient should be monitored for the next 48 hours after beginning antibiotic treatment. In patients who do not show any complications, they should be monitored daily and the presence of any potential existing risk factors should be investigated. If fever persists following 48 hours, it means there is some other type of infection e.g. a fungal infection. If the fever continues beyond 5 days, then the patient should be checked with a chest CT scan. Experts in clinical microbiology and infectious diseases should be consulted and, if needed, antifungal medications (e.g. liposomal amphotericin B, caspofungin, voriconazole) should be initiated.

If there is no fever following 48 hours, then the intravenous infusion of antibiotics may be switched to oral antibiotics. Eventually after a week, the antibiotics may be discontinued. The neutrophil count may not be more than 0.5 x 10⁹/l at this point.

Patients with neutropenia can be given Granulocyte-colony stimulating factor (G-CSF) injections to stimulate the marrow to produce granulocytes to help fight recurrent infections. The most commonly used agent is filgrastim.

How can you Prevent Neutropenic Sepsis?

Taking the following precautions may help prevent or reduce risk of neutropenic sepsis in a patient with neutropenia

Maintain good personal hygiene and frequent handwashing
Avoid crowds and persons who are unwell
Using soft toothbrush
Washing and cooking food thoroughly before eating
Regular bathing and shower
Wear footwear when going outdoors
Being careful while shaving

References:

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Kruse JM et al., �Neutropenic Sepsis in the ICU: Outcome Predictors in a Two-Phase Model and Microbiology Findings,� Critical Care Res and Pract. 2016;2016, Article ID 8137850, 9 pages. - (https://doi.org/10.1155/2016/8137850)
Clarke RT et al. Neutropenic sepsis: management and complications. Clin Med. 2013;13(2):185-187.
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O. Penack, D. Buchheidt, M. Christopeit, M. von Lilienfeld-Toal, G. Massenkeil, M. Hentrich, H. Salwender, H.-H. Wolf, H. Ostermann; Management of sepsis in neutropenic patients: guidelines from the infectious diseases working party of the German Society of Hematology and Oncology, Annals of Oncol. 2011;Vol 22(5):1019�1029.
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National Collaborating Centre for Cancer. Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients. 2012. - (https://www.nice.org.uk/guidance/cg151/evidence/evidence-review-pdf-188303582)
Mapes D. Hutch news: After chemotherapy, immune system recovery may be slower than believed. Updated Jan 26, 2016. Accessed Mar 18, 2019. - (https://www.fredhutch.org/en/news/center-news/2016/01/chemotherapy-immune-system.html)

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