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Chemotherapy-associated neutropenic sepsis — MRCEM SBA MCQ

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HardInfection and sepsisChemotherapy-associated neutropenic sepsisMRCEM SBA

A 54-year-old woman attends the emergency department eight days after chemotherapy for breast cancer. She reports rigors and profound malaise but no focal symptoms. Her temperature is 35.8°C, pulse 114/min, respiratory rate 23/min and blood pressure 112/70 mmHg. She is alert. Her neutrophil count is 0.2 × 10⁹/L and venous lactate is 1.7 mmol/L. She has an implanted central venous port with no tenderness, erythema or discharge. Blood cultures have been taken. She has no antibiotic allergy or known colonisation with resistant organisms, and local microbiology guidance identifies no additional empirical cover. Which initial treatment and disposition plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Start intravenous piperacillin–tazobactam alone; retain the port; admit for specialist risk assessment.

This patient needs immediate treatment for suspected neutropenic sepsis. Recent chemotherapy, a neutrophil count below 0.5 × 10⁹/L and systemic illness establish the concern despite the absence of fever: NICE accepts other signs of clinically significant sepsis in place of a temperature above 38°C. The normal lactate and preserved blood pressure do not justify delaying antibiotics. ([nice.org.uk](https://www.nice.org.uk/guidance/cg151/chapter/recommendations)) In the absence of a patient-specific or local microbiological contraindication, NICE recommends intravenous piperacillin–tazobactam monotherapy initially. A adds gentamicin without a microbiological indication. B adds vancomycin because a port is present, but central access alone does not justify empirical glycopeptide treatment. C removes the port before evidence establishes a need for removal; NICE advises against removing central access as part of initial empirical management. ([nice.org.uk](https://www.nice.org.uk/guidance/cg151/chapter/recommendations)) D offers an oral regimen before initial intravenous treatment and specialist risk stratification. Selected patients assessed as being at low risk may subsequently be considered for outpatient antibiotic treatment, but apparent haemodynamic stability is not itself that assessment. E provides prompt recommended therapy while retaining the port and arranging specialist assessment of her risk of septic complications. ([nice.org.uk](https://www.nice.org.uk/guidance/cg151/chapter/recommendations))

Reference: NICE CG151: Neutropenic sepsis — recommendations 1.4.1 and 1.4.4 (19 September 2012) — https://www.nice.org.uk/guidance/cg151/chapter/recommendations NICE CG151: Neutropenic sepsis — recommendation 1.4.3 (19 September 2012) — https://www.nice.org.uk/guidance/cg151/chapter/recommendations NICE CG151: Neutropenic sepsis — recommendations 1.5.1 and 1.5.2 (19 September 2012) — https://www.nice.org.uk/guidance/cg151/chapter/recommendations