CLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN ADULT CANCER PATIENTS (this guideline excludes haematology patients) 1. Aim/Purpose of this Guideline 1.1. Systemic cancer treatments and immunological therapies can suppress the ability of the bone marrow to respond to infection. Neutropenic sepsis is a potentially fatal complication of anticancer and immunological treatment, particularly chemotherapy. 1.2. Successful management involves immediate assessment and commencement of antibiotics within 60 minutes. 1.3. This guideline aims to improve outcomes for patients at risk of neutropenic sepsis, by providing evidence based recommendations for practice. It is intended for the use by medical nursing and pharmacy staff. 2. The Guidance 2.1. Information, support and training 2.2. Patients receiving anticancer and immunological treatments and their carers should be provided with oral and written information on: Neutropenic sepsis How and when to seek emergency advice How and when to contact 24 hour specialist advice This information is provided via the Chemotherapy contact card, 24 hour contact no: 07833057447. 2.3. Healthcare professionals and staff involved in the care of patients receiving anticancer treatments should be provided with training on neutropenic sepsis, which should be tailored according to the type of contact. Training will be provided by or under the guidance of the Acute Oncology Nurse Practitioner, this will be provided as face to face sessions held in each area. 2.4. Reducing the risk of septic complications of anticancer treatment 2.5. For adult patients with solid tumours (i.e. non-haematological cancer) in whom significant neutropenia (neutrophil count 0.5x10 9 per litre or lower) is an anticipated consequence of chemotherapy offer prophylaxis with a fluoroquinolone during the expected period of neutropenia ( NICE 2012). The microbiology approved agent for this indication within RCHT is ciprofloxacin. 2.6. Rates of antibiotic resistance and infection patterns should be monitored where patients are having fluoroquinolones for the prophylaxis of neutropenic sepsis. (NICE 2012)
2.7. G-CSF (Granulocyte-colony stimulating factor) should not be routinely offered for the prevention of neutropenic sepsis in adults receiving chemotherapy unless an integral part of the chemotherapy regime. (NICE 2012) Neutropenia Neutrophil count 0.5 x 109/L Definition Neutropenia Neutrophil count < 0.5 x 10 9 /L Neutropenic sepsis Neutrophil count < 0.5 X 10 9 /L and either clinical signs of infection or a temperature of 38 o C MASCC risk index Scoring system for the proposed risk index (Multinational association for supportive for identifying low risk neutropenic sepsis care in cancer). patients. Contact information Microbiology - 4900 Acute Oncology Service bleep Clinical Nurse Specialist via switchboard Oncology consultant on call via switchboard
Initial management of oncology chemotherapy related sepsis (possible neutropenic sepsis) For all patients with suspected or confirmed neutropenic sepsis (generally unwell with signs/symptoms of sepsis and/or temperature 38 o C AND history of receiving anticancer therapy ) Assume: Neutropenic sepsis until proven otherwise Urgent Assessment History and examination Observations Venous access (Blood cultures, FBC, U&E, LFT, Lactate, CRP) Sepsis? i.e. signs and symptoms of end organ dysfunction including Altered mental state or Hypoxia (O 2 sats < 94%) or Shock (Systolic BP < 90mmHg)Oliguria YES Resuscitation Immediate 1st Line antibiotics Consider HDU/ITU NO Treat suspected neutropenic sepsis as an acute medical emergency GIVE ANTIBIOTICS IMMEDIATELY Do NOT wait for the FBC Follow RCHT sepsis management guidelines (eg fluid resuscitation etc) Penicillin allergy? Yes history of anaphylaxis No Yes history of non-immediate reaction Ciprofloxacin IV 400mg BD Piperacillin tazobactam IV 4.5g TDS Minor or rash - Ceftazidime IV 2g TDS ESBL carrier use Guided by previous resistance profile Meropenem IV 500mg QDS
Management of neutropenic sepsis caused by systemic anti-cancer treatments Confirmed neutropenic sepsis Neutrophil count 0.5 x 10 9 /L and temperature 38º or other signs/symptoms consistent with clinically significant sepsis (if neutrophil count falling and expected to fall to <0.5 also include as neutropenic) Continue antibiotics Refer to RCHT antibiotic policy for Neutropenic sepsis as above Perform RISK ASSESSMENT (MASCC score) Contact Acute Oncology team MASCC (multi-national association for supportive care in cancer) risk assessment used to differentiate between high risk and low risk patients who have already been identified as stable. Characteristic Age >60 years = 0 < 60 years =2 Dehydrated requiring No =3 fluids? Yes = 0 Systolic Blood pressure <90 = 0 > 90 = 5 COPD? Yes = 0 No = 4 Solid tumour or Yes = 4 haematological malignancy No = 0 with no previous fungal infection? Symptoms related to this infective neutropenic episode? Already an inpatient before this episode of infective neutropenia? Total score None = 5 Mild = 5 Moderate = 3 Severe = 0 Yes = 0 No = 3 > 21 = low risk < 21 high risk Score
21 or more LOW risk of complications Less than 21 HIGH risk of complications Consider switch to oral antibiotics after 24-48 hours IV treatment as per the IV to oral switch criteria below. Antibiotic choice guided by culture and sensitivities. If blood culture negative then ciprofloxacin to complete five days. Consider discharge if social and clinical circumstances permit Continue to manage as an inpatient and consider IV to oral switch after 24-48 hours with choice of agent guided by cultures and sensitivities. If blood culture negative then ciprofloxacin to complete for five days.
Does the patient meet the following IV to oral switch criteria? 1. Clinical condition of the patient is improving and haemodynamically stable; HR <100 beats per minute for at least 12 hours with no unexplained tachycardia, Systolic blood pressure >100mmHg, Respiratory rate <20 breaths per minute and no tachypnoea). Afebrile for at least 24 hours (temperature < 38 C oral). Neutrophil count that is rising and above 0.5 2. Able to tolerate oral medication and appropriate oral antimicrobial available. Functioning gastrointestinal tract without risk of malabsorption. 3. No haematological malignancy 4. No serious deep-seated infection that requires high-dose IV (see below) Meningitis and CNS infection, osteomyelitis, discitis or mediastinitis, endocarditis or intravascular infection, septic arthritis, Legionella pneumonia, abscess or empyema not drained, exacerbations of cystic fibrosis and bronchiectasis, Staphylococcus aureus bacteraemia, infection of prosthetic device or foreign body, severe soft tissue infections such as necrotising fasciitis. Special points 1. If patient is not neutropenic (neutrophil count >1.7) then treat according to RCHT antibiotic guidelines with antibiotic choice determined by infection source. 2. Ensure robust framework for checking microbiology results if patient discharged before culture results available. 3. Patient should have daily FBC checked until neutrophil count rising and above 0.5 x 109 4. Ensure the RCHT sepsis pathway is followed for all neutropenic sepsis patients.
5.Monitoring compliance and effectiveness This part must provide information on the processes and methodology for monitoring compliance with, and effectiveness of, the policy using the table below. Element to be monitored Lead Tool Frequency Reporting arrangements Appropriate management of those patients identified as neutropneic and those patients identified as not neutropenic. Timely IV to oral switch of antibiotics. Appropriate total antibiotic course lengths. Acute Oncology team supported by the Antibiotic stewardship team Audit tool developed on key parameters within these guidelines Monitored six monthly with a report send to the Infection Control Committee for inclusion in their annual report Antibiotic stewardship management committee, Oncology Governance Group, Medicines Practice Committee and Hospital Infection Control Committee. Acting on recommendations and Lead(s) Change in practice and lessons to be shared Oncology Governance and Medicines Practice Committee a specified timeframe Through the Clinical Oncology governance meetings. 1. Equality and Diversity 1.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 1.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information Document Title Date Issued/Approved: 07 July 2017 CLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS Date Valid From: 07 July 2017 Date Valid To: 07 July 2020 Directorate / Department responsible (author/owner): Dr Jon McGrane Contact details: Brief summary of contents Appropriate management of neutropenic sepsis in oncology patients Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and neutropenia sepsis, oncology, cancer RCHT PCH CFT KCCG Medical Director New Document Clinical oncology governance Medicines Practice Committee Divisional Manager Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Intranet Only
Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Clinical Oncology Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) V1.0 Version 1 [Please complete all boxes and delete help notes in blue italics including this note] All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.
Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): CLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS Directorate and service area: Is this a new or existing Policy? Acute Oncology New Name of individual completing Telephone: assessment: Neil Powell 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* 3. Policy intended Outcomes* Appropriate management of those patients identified as neutropenic and those cancer patients identified as not neutropenic with timely IV to oral switch of antibiotics and appropriate total antibiotic course lengths. 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure.
7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission 5/9/14
Names and signatures of members carrying out the Screening Assessment 1. 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date d