Management of sepsis in neutropenic patients: 2014 updated guidelines from the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO)

Abstract

Sepsis is a major cause of mortality during the neutropenic phase after intensive cytotoxic therapies for malignancies. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. Clinical guidelines on sepsis treatment have been published by others. However, optimal management may differ between neutropenic and non-neutropenic patients. Our aim is to give evidence-based recommendations for haematologist, oncologists and intensive care physicians on how to manage adult patients with neutropenia and sepsis.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

“…The reader is directed to guidelines that provide potential regimens based on anatomic site of infection or specific immune defects [67,[99][100][101][102][103][104][105][106][107][108][109].…”

“…In the case of neutropenia in the absence of septic shock, studies using modern broad-spectrum antibiotics consistently suggest that, while multidrug therapy to broaden pathogen coverage (e.g., to include Candida species) may be useful, combination therapy using a β-lactam and an aminoglycoside for purposes of accelerating pathogen clearance is not beneficial for less severely ill "low-risk" patients [187]. Combination therapy of this sort for even "high-risk" neutropenic patients (inclusive of hemodynamic instability and organ failure) with sepsis is inconsistently supported by several international expert groups [106,188]. This position against combination therapy for a single pathogen in any form of neutropenic infection emphatically does not preclude the use of multidrug therapy for the purpose of broadening the spectrum of antimicrobial treatment.…”

Bloodstream infections in neutropenic cancer patients: A practical update

“…8,13,132 Only German experts suggest, with a low level of evidence, the inclusion of an aminoglycoside in the initial empirical therapy in case of severe sepsis or septic shock, based on the results coming from a large retrospective study. 26,133 In settings with low prevalence of resistance among GN bacteria, there is no benefit of using very broad spectrum agents, such as carbapenems, compared to the aforementioned cephalosporins and piperacillin/tazobactam. However, many centers report nowadays high rates of BSIs caused by ESBL-producing Enterobacteriaceae.…”

“…8,25 Moreover, the occurrences of severe sepsis and septic shock in the setting of febrile neutropenia have been estimated to be, respectively, 20-30% and 5-10%. [26][27][28] Epidemiology of bacterial BSI…”

Granulocyte transfusion: questions remain

“…For patients undergoing stem cell transplantation or induction for acute leukemia, modern intensive chemotherapy often results in prolonged periods of neutropenia, a major risk factor for severe bacterial and fungal infections. 2,3 Despite the administration of granulocyte colony-stimulating factor and appropriate antimicrobials, systemic infections in patients with neutropenia are associated with extended hospital admission, organ damage, and a significant mortality, which in some series reaches .20%. 3 Clinical experience and data from animal studies suggest that control of infection in these patients requires the recovery of bone marrow neutrophil production.…”