Septic shock is a leading cause of death in chemotherapy-treated patients with neutropenia, and updated guidelines for managing sepsis in this setting were recently published in Annals of Hematology.
Neutropenia in patients with cancer can be an independent risk factor for infection, especially severe neutropenia (absolute neutrophil count [ANC] below 500/mL) and neutropenia that lasts longer than 7 days. The updated guidelines recommend that patients with symptoms of infection be screened daily for sepsis and that neutropenic patients with cancer be screened daily for signs of acute organ dysfunction.
No significant pathophysiological differences between neutropenic and non-neutropenic patients with cancer were found, which suggests that these patients should not be treated differently.
The guidelines noted that within the first hour of diagnosing a patient with sepsis, the patient’s lactate level should be measured, blood cultures should be drawn, a broad spectrum antibiotic should be administered, fluid should be rapidly administered, and vasopressors should be provided to maintain blood pressure.
Empiric antipseudomonal broad spectrum antibiotics should be started immediately; the guidelines recommend piperacillin and tazobactam, meropenem, or imipenem and cilastatin as the agents of choice. It was noted that an aminoglycoside could be considered as well, though studies have demonstrated increased renal toxicity without improvement in efficacy. The use of corticosteroids in neutropenic patients with sepsis should be evaluated individually.
Red blood cell transfusion was only recommended at hemoglobin levels below 7 g/dL and in the absence of risk factors. Furthermore, platelet transfusions should adhere to the standard trigger level of 10×109/L or below and should be considered on an individual basis.
Source control should be done immediately. In cases of suspected infections, all intravascular devices should be removed. Prophylaxis for venous thromboembolism with unfractionated or low-molecular-weight heparin in the absence of contraindications was also recommended, as was whole-body physiotherapy.
Finally, the guidelines noted that admission to an intensive care unit should not be delayed, and prognosis and treatment goals should be discussed with the patient prior to admission. Enhanced communication, daily re-evaluations of goals and prognosis, and early involvement of relevant specialists were emphasized. Furthermore, the researchers stated that all available resources should be offered to patients in critical care.
- Kochanek M, Schalk E, von Bergwelt-Baildon M, et al. Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Disease Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO)[published online February 22, 2019]. Ann Hematol. doi: 10.1007/s00277-019-03622-0