Neutropenic sepsis: Severity assessment: Identify potential low risk patients (Antimicrobial)

Warning

Once initial workup is complete, calculate MASCC score to assess if the patient is at low risk of complications from febrile neutropenia and therefore suitable for oral therapy, which can be given as an out-patient.

MASCC Score:

POINTS

0

2

3

4

5

Burden of illness (symptom severity)

Severe

 

Moderate

 

None or mild

Hypotension (sBP <90 mmHg)

Yes

 

 

 

No

Active COPD

Yes

 

 

No

 

Solid tumour (or haematological malignancy without prior fungal infection)

No

 

 

Yes

 

Dehydration requiring IV therapy

Yes

 

No

 

 

Status at onset of fever

Inpatient

 

Outpatient

 

 

Age

≥60 years

<60 years

 

 

 

 

MASCC Score = 21 or HIGHER (= likely low risk)

Complete low risk febrile neutropenia checklist:

  • Patient 18 years or older
  • Patient has solid tumour
  • History of temperature at least 37·5 °C OR below 36·1°C
  • Patient has received SACT (systemic anticancer therapy)
  • Patient has absolute neutrophil count less than 1 x 109/L
  • First dose empirical intravenous antibiotics administered
  • Patient has ready access to Emergency Department

The patient should be observed for MINIMUM OF 4 HOURS to ensure clinical stability before considering discharging on ambulatory pathway

Patient stable

Assess if the patient can tolerate oral therapy.

Assess patients for seizure risk or QTc prolongation before prescribing ciprofloxacin.

Consider baseline ECG and monitoring.

 

Patient’s condition deteriorates   

Reassess NEWS and Sepsis Red flags.

Continue in-patient management of neutropenic sepsis.

MASCC Score = 20 or LOWER (= high risk) Continue in-patient management of neutropenic sepsis

NOTE: these oral antibiotics are associated with a high risk of Clostridium difficile infection.  Patients must inform the Cancer Treatment Helpline if they develop diarrhoea and inform the call handler about the current antibiotic therapy.

Drug details

Out-patient therapy for patients assessed as at low risk for complications

Co-amoxiclav 625mg 3 x a day PLUS ciprofloxacin 750mg TWICE a day

5 to 7 days, depending on clinical response

In penicillin allergy

Clindamycin 300mg 4 x a day PLUS ciprofloxacin 750mg TWICE a day

5 to 7 days, depending on clinical response

If ciprofloxacin unsuitable (recent fluoroquinolone therapy or prophylaxis, known fluoroquinolone resistance or previous ADR to fluoroquinolone)

Seek advice from Microbiology

5 to 7 days, depending on clinical response

If known or previous colonisation with MRSA, VRE, ESBL or KPC

Seek advice from Microbiology as oral options given do not provide cover.

5 to 7 days, depending on clinical response

Last reviewed: 27/04/2023

Next review date: 27/04/2026

Author(s): Antimicrobial Management Team.

Version: 3

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Alison Macdonald, Area Antimicrobial Pharmacist.

Document Id: AMT187