Phillips, R., Hancock, B., Graham, J., Bromham, N., Jin, H., & Berendse, S. (2012). Prevention and management of neutropenic sepsis in patients with cancer: Summary of NICE guidance. BMJ, 345, e5368.

 

The purpose of the article was to assess systemic reviews of best available evidence, including consideration of cost, management of neutropenic sepsis leading to avoidable deaths, and the lack of systems for urgent assessment and lack of institutional policies for managing neutropenic sepsis. Adults (aged 18 or older) with acute leukaemias, stem cell transplantations or solid tumors with expected neutropenia of 0.5 x 10⁹/L or less post-chemotherapy were assessed.

This was an evidence-based guideline with a guideline summary process of development.

Inclusion criteria included adult patients receiving chemotherapy. Exclusion criteria included being younger than age 18 and a diagnosis of lymphoma.

The phase of care was active anti-tumor treatment

High-quality evidence based on systematic reviews/meta-analyses of randomized, controlled trials (RCTs), moderate quality evidence based on systematic reviews, experienced opinion of Guideline Development Group (GDG), and National Cancer Action Team referenced as experience and opinion sources. Low-level evidence includes observational studies.

High-quality evidence (systematic reviews/meta-analysies of RCTs):

• Initiate monotherapy antibiotics when neutropenic sepsis suspected as acute emergency
• No routine prophylaxis with G-CSFs
• Monotherapy for first-line empirical antibiotic

Moderate quality evidence (systematic reviews):

• Outpatient antibiotics considered for low-risk patients after screening
• Oncology-trained professional assessment of septic risk complications during first 24 hours using tool validated for risk score

Experienced opinion of Guideline Development Group (GDG):

• Inform caregiver/ patients before chemotherapy about neutropenia risk and management.  Provide verbal and written information before and throughout treatment.
• Train healthcare professionals to identify and manage potential or actual neutropenic sepsis.
• Monitor antibiotic resistance for flouroquinolones used prophylactically for neutropenic sepsis.
• Assess when to begin or continue empirical antibiotic therapy.

Low level evidence (observational studies):

• Chest x-ray, removal of vascular access device (plus GDG guideline) only when clinically indicated
• Temperature greater than 38⁰C and neutrophil count of 0.5 x 10⁹/L as a neutropenic sepsis diagnosis

• Cannot be applied to children, patients younger than 18 years, or anyone with lymphoma. 
• No external peer review.

High-quality evidence exists for practice recommendations:  

• Initiate monotherapy antibiotics when neutropenic sepsis is suspected as acute emergency
• No routine prophylaxis with granulocyte colony stimulating factors differs from other professional guideline recommendations regarding primary and secondary prophylaxis for at-risk patients.
• Monotherapy for first-line empirical antibiotic