OncologyTier 1Disease (DEADMAN)

Neutropenic sepsis

Description

The oncology-service perspective on febrile neutropenia - prevention, patient safety-netting, and the systems response, complementing the infectious-diseases note's detail on empirical antibiotic choice/escalation
Every patient starting myelosuppressive chemotherapy needs an explicit neutropenic sepsis action plan before cycle one - this is a pre-treatment counselling responsibility, not something addressed only once fever occurs

Risk of febrile neutropenia varies hugely by regimen - high-risk regimens (>20% incidence) include many AML induction, and dose-dense/dose-intense solid tumour protocols
Mortality with prompt treatment ~2-5%, but time-to-first-antibiotic-dose is the single strongest modifiable predictor of outcome

Chemotherapy nadir typically 7-14 days post-treatment - patient education must specify this window, not just "call if you get a fever"
Regimen-specific febrile neutropenia risk (high >=20%, intermediate 10-20%, low <10%) determines whether primary prophylaxis is warranted - see Management

The systems failure points to guard against

Patient not recognising a fever as an emergency, or not knowing their neutrophil nadir window
Triage delay in ED - neutropenic sepsis pathways should flag these patients for immediate assessment, bypassing standard triage queues
See febrile neutropenia for MASCC risk stratification and work-up detail once the patient is being assessed

A. Primary prevention - before fever ever occurs

High-risk regimen (>=20% febrile neutropenia incidence) - primary G-CSF prophylaxis recommended from cycle 1
Intermediate-risk regimen (10-20%) - consider G-CSF prophylaxis if additional patient risk factors present (age >65, poor performance status, prior febrile neutropenia, extensive marrow involvement, comorbidities)
Low-risk regimen (<10%) - G-CSF prophylaxis generally not indicated

B. Patient education - mandatory before cycle 1 of any myelosuppressive regimen

Explicit fever threshold (e.g. single temp >=38C) and instruction to present immediately, day or night, without waiting to "see how it goes"
24-hour oncology contact number/pathway, and instruction to inform any treating clinician (including ED) that they are neutropenic/on chemotherapy
Avoid situations with high infection exposure during the expected nadir window

C. The systems response once a patient presents

Door-to-antibiotic time target within 1 hour - hospital neutropenic sepsis pathways/order sets exist specifically to prevent delay from triage, workup, or awaiting senior review
Empirical antibiotic choice, risk stratification (MASCC), and escalation - see febrile neutropenia

D. After an episode - secondary prevention

Secondary G-CSF prophylaxis for subsequent cycles after one episode of febrile neutropenia, if continuing the same regimen at full dose is still intended
Alternatively, dose reduction or regimen modification for future cycles - a multidisciplinary decision weighing efficacy vs toxicity, made with the patient

High-risk myelosuppressive regimens (dose-dense/dose-intense protocols, AML induction, HSCT conditioning)
Older age, poor performance status, comorbidities, prior febrile neutropenia episode - additional individual risk factors
Poor patient understanding of the nadir window/action plan - a preventable systems failure

Effective primary prophylaxis and patient education programs measurably reduce febrile neutropenia incidence and hospital presentation delay
A single episode of febrile neutropenia often changes the trajectory of subsequent treatment - triggers reassessment of regimen dose/intensity and addition of G-CSF support
Delay at any point in the pathway (patient recognition, triage, antibiotic administration) is the recurring theme in preventable adverse outcomes - not typically antibiotic choice itself

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