Septic shock in the immunocompromised cancer patient: a narrative review

Abstract

Immunosuppressed patients, particularly those with cancer, represent a momentous and increasing portion of the population, especially as cancer incidence rises with population growth and aging. These patients are at a heightened risk of developing severe infections, including sepsis and septic shock, due to multiple immunologic defects such as neutropenia, lymphopenia, and T and B-cell impairment. The diverse and complex nature of these immunologic profiles, compounded by the concomitant use of immunosuppressive therapies (e.g., corticosteroids, cytotoxic drugs, and immunotherapy), superimposed by the breakage of natural protective barriers (e.g., mucosal damage, chronic indwelling catheters, and alterations of anatomical structures), increases the risk of various infections. These and other conditions that mimic sepsis pose substantial diagnostic and therapeutic challenges. Factors that elevate the risk of progression to septic shock in these patients include advanced age, pre-existing comorbidities, frailty, type of cancer, the severity of immunosuppression, hypoalbuminemia, hypophosphatemia, Gram-negative bacteremia, and type and timing of responses to initial treatment. The management of vulnerable cancer patients with sepsis or septic shock varies due to biased clinical practices that may result in delayed access to intensive care and worse outcomes. While septic shock is typically associated with poor outcomes in patients with malignancies, survival has significantly improved over time. Therefore, understanding and addressing the unique needs of cancer patients through a new paradigm, which includes the integration of innovative technologies into our healthcare system (e.g., wireless technologies, medical informatics, precision medicine), targeted management strategies, and robust clinical practices, including early identification and diagnosis, coupled with prompt admission to high-level care facilities that promote a multidisciplinary approach, is crucial for improving their prognosis and overall survival rates.

Keywords: Critical care; Critical care outcomes; Hematologic neoplasms; Hematopoietic stem cell transplantation; Immunocompromised host; Neoplasms; Organ transplantation; Septic shock.

Fig. 1

Clinical vignettes: The need for a prompt admission to the ICU should be addressed for each vignette presented here

Fig. 2

New Paradigm. Despite a rise in prevalence and severity of septic shock in immunosuppressed patients, survival has improved over time. An advanced stage of the disease should not deter from ICU admission, nor the use of novel technologies such as wearable devices, outreach programs, artificial intelligence, and machine learning models for early detection and diagnosis. Critical care should remain in line with values and preference of the patient supported by their family