Neutropenic sepsis
- Neutropenic sepsis is a medical emergency and requires prompt treatment with effective antimicrobials. Fever may not always be present. Patients with neutropenic sepsis are at risk of severe sepsis, septic shock and death.
- Antibiotics should be given within 1 hour of arrival in hospital.
- Clinicians not experienced in the management of this condition must contact their senior. Cases should be discussed with relevant cancer service and Micro/ID.
- Antibiotics must be reviewed at 24 hours, risk assessment made and treatment modified as appropriate.
- For patients on high dose methotrexate (1g per m2 or greater) DO NOT use piperacillin-tazobactam (see additional information below)
For prescribing use 'Neutropenic sepsis adult powerplan' on EPR.
Review empirical treatment within 24 - 48 hours
See also Sepsis Identification and Management and Guideline for the management of neutropenic sepsis in adults
Preferred
piperacillin-tazobactam 4.5g iv stat (first dose) should be given as soon as possible (ideally within 60 mins) THEN one of the following regimens should be used, choose from:
Extended infusion piperacillin-tazobactam 4.5g iv tds infuse each dose over 3-4 hours (six hours after the initial stat dose)
OR
piperacillin-tazobactam 4.5g iv qds (six hours after the initial stat dose)
OR
Elastomeric pump piperacillin-tazobactam 13.5g over 24 hours (elastomeric device should be attached straight after the initial stat dose)
Alternative
For penicillin allergy (non-severe)
meropenem 1 gram iv tds
For penicillin allergy (severe)
ciprofloxacin 400mg iv bd (or 500mg po bd)
+ vancomycin iv
Modifications to empiric selection
For patients with neutropenic sepsis AND severe symptoms: Consider adding gentamicin 5mg/kg iv single dose. See gentamicin monograph for dosing (including renal dosing).
For patients with neutropenic sepsis on protocols with high dose methotrexate (1g per m2 or greater) OR with a diagnosis of osteosarcoma with planned high dose methotrexate treatment: meropenem 1g iv tds
For patients with neutropenic sepsis AND likely/suspected vascular catheter infection OR MRSA positive: ADD vancomycin iv
For patients with neutropenic sepsis AND perianal sepsis/ abdominal pain/ dental infection/ diarrhoea: ADD metronidazole 400mg po tds
For patients with neutropenic sepsis AND severe lobar pneumonia consider risk of Legionnaires: See Legionnaires disease
For patients with neutropenic sepsis where IV access is likely to be delayed more than 60 minutes: Discuss with Micro/ID for consideration of interim oral options
Additional information
Co-administration of penicillin has been shown to reduce tubular secretion of methotrexate, leading to potential toxicity. In a high dose methotrexate setting (1g per m2 or greater), penicillin should be avoided until all methotrexate is cleared from the body (plasma methotrexate level less than 0.1 micromol/L). Penicillin should also be avoided between methotrexate infusions in osteosarcoma patients because of high dose intensity of treatment and predisposition to toxicity.