Neutropenic sepsis after chemotherapy — FFICM MCQ

Correct answer: B — Administer empirical intravenous antipseudomonal beta-lactam therapy

The correct answer is B, administer empirical intravenous antipseudomonal beta-lactam therapy. This patient has neutropenic sepsis (neutrophils 0.2 x 10^9/L, fever, rigors) with septic shock (MAP 58 mmHg, lactate 3.6 mmol/L), which is a medical emergency where mortality rises with every hour antibiotics are delayed. Neutropenic patients lack the neutrophils to mount a localising inflammatory response, so a normal line site and clear chest X-ray do not exclude serious infection, including from Pseudomonas aeruginosa and other gram-negatives that can rapidly progress to fatal sepsis. NICE guidance mandates piperacillin with tazobactam (an antipseudomonal beta-lactam) monotherapy as first-line empirical treatment, to be given within one hour of suspected neutropenic sepsis being identified, without waiting for cultures or senior review. Why the other options are wrong: E. Wait for neutropenic recovery before treatment: neutrophil recovery may take days and this patient is already in shock; withholding antibiotics until recovery would be fatal. A. Give oral co-amoxiclav as initial therapy: oral therapy has unreliable absorption in a shocked, unwell patient and co-amoxiclav lacks reliable antipseudomonal cover, which is essential in profound neutropenia. C. Remove the central line before any antibiotics: the line looks clinically normal and there is no confirmed line infection; removing it first would delay life-saving antibiotics and is not indicated as an immediate priority. D. Start granulocyte transfusion as first-line therapy: granulocyte transfusions are not first-line, have limited evidence of benefit, carry transfusion-related risks, and are reserved for refractory cases unresponsive to antimicrobials, not initial management. Key point: In neutropenic sepsis with shock, empirical IV antipseudomonal beta-lactam monotherapy (piperacillin-tazobactam) must be given within one hour, before source control or culture results, because absent localising signs do not exclude life-threatening infection.

Reference: NICE Clinical Guideline CG151, Neutropenic sepsis: prevention and management in people with cancer, recommendation 1.4.3.1 (piperacillin with tazobactam beta-lactam monotherapy as initial empiric antibiotic therapy), www.nice.org.uk/guidance/cg151