NICE clinical guidelines
Issued: September 2012
CG151

Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg151

Introduction

Neutropenic sepsis is a potentially fatal complication of anticancer treatment (particularly chemotherapy). Mortality rates ranging between 2% and 21% have been reported in adults. Aggressive use of inpatient intravenous antibiotic therapy has reduced morbidity and mortality rates and intensive care management is now needed in fewer than 5% of cases in England.

Systemic therapies to treat cancer can suppress the ability of bone marrow to respond to infection. This is particularly the case with systemic chemotherapy, although radiotherapy can also cause such suppression.

Chemotherapy is most commonly given in a day-case or outpatient setting so most episodes of obvious sepsis, and fever in a person with potential sepsis, present in the community. People receiving chemotherapy and their carers need to be told about the risk of neutropenic sepsis and the warning signs and symptoms. Neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment.

A report by the National Confidential Enquiry into Patient Outcome and Death (Systemic anti-cancer therapy: for better for worse? [2008]) and a follow-up report by the National Chemotherapy Advisory Group (Chemotherapy services in England: ensuring quality and safety [2010]) highlighted problems in the management of neutropenic sepsis in adults receiving chemotherapy. These problems included inadequate management of neutropenic fever leading to avoidable deaths, and a need for systems for urgent assessment and organisation-level policies for dealing with neutropenic fever. The reports also noted variation in the provision of information on the treatment of side effects and on access to 24-hour telephone advice.

In addition, there is national variation in the use of:

  • primary and secondary prophylaxis

  • risk stratification in episodes of febrile neutropenia

  • oral or intravenous antibiotics

  • growth factors

  • inpatient or outpatient management policies.

This guideline aims to improve outcomes by providing evidence-based recommendations on the prevention, identification and management of this life-threatening complication of cancer treatment.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.