Empirical antimicrobial treatment in haemato-/oncological patients with neutropenic sepsis

Abstract

Neutropenic sepsis in haemato-/oncological patients is a medical emergency, as infections may show a fulminant clinical course. Early differentiation between sepsis and febrile neutropenic response often proves to be challenging. To assess the severity of the illness, different tools, which are discussed in this article, are available. Once the diagnosis has been established, the correct use of early empirical antibiotic and antifungal treatment is key in improving patient survival. Therefore, profound knowledge of local resistance patterns is mandatory and carefully designed antibiotic regimens have to be established in cooperation with local microbiologists or infectious diseases specialists. In the following, identification, therapy and management of high-risk, neutropenic patients will be reviewed based on experimental and clinical studies, guidelines and reviews.

Keywords: anti-infective agents; antimicrobial resistance; fever; neutropenia; sepsis.

Figure 1

Therapeutic escalation approach in septic neutropenic patients. ¹High/intermediate risk, ²low risk, ³continue treatment, ⁴currently under development, ⁵use therapeutic drug monitoring, target values 40–60 mg/L. MRGN, multidrug-resistant Gram negative; MRSA, methicillin-resistant Staphylococcus aureus.

Figure 2

Antifungal prophylaxis and treatment in septic neutropenic patients. ¹Type of antifungal prophylaxis (fluconazole vs antimould agent) and underlying illness influence the likelihood if invasive mould infection; ²factors predisposing for fungal infection: prior organ and/or stem cell transplantation (HLA-matched related>unrelated donors), chemotherapy with prolonged neutropenia (>10 days), steroid therapy (>7 days), biologics therapy, HIV or prior admission to intensive care unit (>7 days); ³avoid intravenous administration due to renal toxicity of the solvent; ⁴drug monitoring; ⁵ alternative in cases of renal impairment.