Antibiotic Management of
Neutropenic Sepsis at
The James Cook University Hospital
Dr Katherine Watson
ST1 Microbiology
Introduction

Review of trust antibiotic policy using:
 Neutropenic
Sepsis: Prevention and
Management of Neutropenic Sepsis in
Cancer Patients. NICE Guidelines,
September 2012
Local antibiotic resistance rates in gram
negative bacteraemias

NICE Guidelines

All patients should be offered:
 Prophylaxis
with fluoroquinolone antibiotics
during expected periods of neutropenia
 Piperacillin/tazobactam
as initial empiric
antibiotic therapy
 Aminoglycosides

not recommended
“Unless patient specific or local
microbiological contraindications”
Current Trust Antibiotic Policy
Neutrophil count < 1.0 x 10 9 /L plus any of the following:

Temp. > 38oC at any time
 Rigors
 Hypothermia
 Unexplained hypotension
 Unexplained deterioration without pyrexia


Patients must receive intravenous antibiotics within 1 hour of presentation

First Line Antibiotic (pending culture results)
Piperacillin/Tazobactam 4.5g tds

+
Gentamicin 5mg/kg stat
Methods

APEX search
 Positive
blood cultures for patients under care of
haematology consultants

Information recorded:
 Organism
identification
 Antibiotic sensitivities of gram negative bacteria
 Piperacillin/tazobactam, meropenem, ciprofloxacin,
gentamicin
Positive Blood Cultures

512 positive blood culture bottles taken between
February 2009 and October 2012

151 patients

600 organisms cultured
 267
gram positive bacteria (44.5%)
 329 gram negative bacteria (54.8%)
 4 fungi (0.7%)
Bacteria Identified

329 Gram negative bacteria:
 108
E.coli
 103 KESC group
 60
Pseudomonas sp.
 23
Stenotrophomonas maltophilia
 11
Acinetobacter sp.
 24
Other gram negative bacteria
33.0%
31.3%
18.2%
6.9%
3.3%
7.3%
Antibiotic Resistance
Pip/tazo
Meropenem Ciprofloxacin Gentamicin
S
R
S
R
S
R
S
R
E.coli
99
9
108
0
105
3
107
1
Pseudomonas
sp.
59
1
50
10
59
1
59
1
KESC group
86
17
103
0
94
9
95
8
Acinetobacter
sp.
11
0
11
0
11
0
7
4
All others
12
8
7
3
18
3
17
2
4%
94%
6%
95%
5%
Total
88% 12% 96%
S=sensitive, R= resistant. Not all organisms have full sensitivities available on APEX, S. Maltophilia not included as
poor correlation between antibiotic susceptibility and treatment outcome
1. Fluoroquinolone Prophylaxis


94% of gram negative bacteria sensitive to ciprofloxacin
However concerns regarding:
 Risk
of antibiotic associated Clostridium difficile
 Development of antibiotic resistance

Action
 Use
of fluoroquinolone prophylaxis still under
consideration
2. Piperacillin/tazobactam

Local resistant rate of 12% in gram negative bacteria

35 piperacillin/tazobactam resistant gram
negative bacteria
 12 individuals, 2 with recurrent

bacteraemias
Action
 Continue
to use as part of first line treatment of
neutropenic sepsis
 Not to use as a single agent
3. Aminoglycosides

99.2% of gram negative bacteria sensitive to
either piperacillin/tazobactam or gentamicin

Only 2 bacteraemias resistant to both
piperacillin/tazobactam and gentamicin

Action
 Gentamicin will continue to be given for at least
the first 24 hours after admission
 To be
reviewed with clinical response and culture
results
Conclusion

First line treatment of neutropenic sepsis to remain
as piperacillin/tazobactam and gentamicin
 High
resistance rates to NICE recommended empiric
agent

NICE guidelines comment on importance of local
resistance patterns
 “High
rates of resistance to chosen empiric agent could
lead to treatment failure”
Any Questions?
Katherine.watson@stees.nhs.uk