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Chemotherapy-associated neutropenic sepsis — MRCEM SBA MCQ

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EasyInfection and sepsisChemotherapy-associated neutropenic sepsisMRCEM SBA

A 54-year-old woman attends the emergency department nine days after chemotherapy for breast cancer. She recorded a temperature of 38.4°C at home and took paracetamol. Her temperature is now 37.5°C, blood pressure 122/76 mmHg and pulse 96/min. She is alert and has no localising symptoms. Her neutrophil count is 0.2 × 10⁹/L. She has an implanted venous port with no erythema or tenderness. Peripheral and port blood cultures have been taken. She has no antibiotic allergy or previous resistant isolates, and there is no relevant local microbiological alert. What is the most appropriate initial antibiotic and place-of-care plan?

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Correct answer: E — Give intravenous piperacillin–tazobactam alone immediately; admit for specialist assessment.

The recorded temperature above 38°C and neutrophil count of 0.2 × 10⁹/L establish neutropenic sepsis in a patient receiving anticancer treatment. Her lower temperature after paracetamol and preserved blood pressure do not make initial treatment less urgent. NICE recommends immediate empirical antibiotics and intravenous piperacillin–tazobactam monotherapy when intravenous treatment is needed, unless patient-specific or local microbiological factors indicate otherwise. She needs hospital-based specialist assessment; suitability for outpatient treatment is a subsequent risk-assessed decision, not an assumption based on her current observations. ([nice.org.uk](https://www.nice.org.uk/guidance/cg151/chapter/Recommendations)) **A:** A venous port makes line infection worth investigating, but the port alone is not an indication for an empirical glycopeptide; there is no local evidence of port infection here. **B:** Routine addition of an aminoglycoside is not recommended without a patient-specific or local microbiological indication. **C:** Outpatient antibiotics can be considered after confirmed neutropenic sepsis has been assessed as low risk, taking clinical and social circumstances into account; that assessment has not occurred. **D:** Cultures have appropriately been taken, but awaiting their results would delay treatment of an acute medical emergency. ([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 (Published 19 September 2012) — https://www.nice.org.uk/guidance/cg151/chapter/Recommendations NICE CG151: Neutropenic sepsis — recommendations 1.4.3 and 1.5.1–1.5.2 (Published 19 September 2012; prophylaxis recommendations amended September 2024) — https://www.nice.org.uk/guidance/cg151/chapter/Recommendations