NICE, the healthcare guidance body has today (19 September) published a new guideline which aims to address shortcomings in the prevention and management of neutropenic sepsis, an increasingly common and potentially fatal complication of cancer treatment, in children, young people and adults with cancer.

Systemic therapies, particularly chemotherapy, to treat cancer carry with them the risk of suppressing the bone marrow's ability to produce neutrophils, a type of white blood cell, thereby affecting the body's capacity to combat infection. When they are neutropenic, patients are vulnerable to rapid onset invasive infection, or sepsis, which can potentially cause overwhelming sepsis and death. Neutropenic sepsis is relatively common, resulting in hundreds of hospital admissions every month and causing the deaths of an estimated 1 in 500 people diagnosed with cancer.

It has been estimated that the total number of deaths from neutropenic sepsis in England and Wales has more than doubled over the last 10 years from around 300 in 2001 to around 700 in 2011. There is also evidence to suggest that, although the numbers of cancers diagnosed each year is increasing, as a proportion of those, the relative rate of neutropenic sepsis deaths also continues to rise. Neutropenic sepsis is also the second most common reason for hospital admission among children and young people with cancer, with approximately 4000 episodes occurring annually in the UK.

Recent reports from the National Confidential Enquiry into Patient Outcome and Death (Systemic anti-cancer therapy: for better for worse?) [2008] and the National Chemotherapy Advisory Group (Chemotherapy services in England: ensuring quality and safety) [2010] highlighted problems with the management of neutropenic sepsis in adults. These included the need for systems for urgent assessment and Trust-level policies for dealing with neutropenic fever, variation in the provision of information on treatment of side effects and access to 24-hour telephone advice. There is also evidence of national variation in the use of primary and secondary antibiotic prophylaxis and bone marrow growth factor prophylaxis; thresholds for diagnosis, criteria for referral to secondary or tertiary care; oral or intravenous antibiotics; bone marrow growth factors, and inpatient or outpatient management policies.

Key priorities for implementation identified in the guideline include:

• Treat suspected neutropenic sepsis as an acute medical emergency and offer antibiotic therapy immediately.
• Diagnose neutropenic sepsis in patients having anti-cancer treatment whose neutrophil count is equal to or lower than 0.5 x 10⁹/litre and who have either:
  
  - a temperature higher than 38^oC or
  
  - other signs or symptoms consistent with clinically significant sepsis.
• Provide patients undergoing anti-cancer treatment and their carers with written and oral information before starting and throughout treatment on:
  
  - neutropenic sepsis
  
  - how and when to contact 24-hour specialist oncology advice
  
  - how and when to seek emergency care.
  
• A healthcare professional with competence in managing complications of anti-cancer treatment should assess the patient's risk of septic complications within 24 hours of presentation to secondary or tertiary care, basing the risk assessment on presentation features and using a validated risk scoring system[1].

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment. However, despite the potentially life-threatening nature of the condition, there is a great deal of uncertainty regarding its definition, prevention, diagnosis and treatment including a lack of systems for urgent assessment and of policies at organisation level for dealing with neutropenic sepsis. This guideline aims to reduce the number of avoidable deaths and improve outcomes for patients presenting with this important complication of anti-cancer treatments by clearly defining the clinical signs and symptoms of neutropenic sepsis that should prompt a timely diagnosis. It also defines a clear pathway for the effective management and treatment of cancer patients presenting with the condition, as well as highlighting the most effective strategies for its prevention."

Professor Barry W Hancock OBE, Emeritus Professor of Oncology, University of Sheffield and Chair of the guideline development group, said: "Neutropenic sepsis is a potentially fatal complication of anti-cancer treatment, particularly chemotherapy. This guideline aims to improve outcomes by providing evidence-based recommendations on prevention, identification and management. It emphasises the importance of information and support for patients of all ages, and their carers; training healthcare professionals; reducing the risk of septic complications; managing suspected neutropenic sepsis in secondary and tertiary care, and providing emergency and continuing clinical care, particularly antibiotic therapy."

Dr Barbara Cross, Consultant Medical Oncologist, Calderdale & Huddersfield NHS Foundation Trust, and member of the guideline development group, said: "I was pleased to be involved in the development of this guideline, addressing as it does an important area of clinical practice in cancer care. The guideline offers a comprehensive review of the current evidence regarding the identification, treatment and prevention of neutropenic sepsis and offers recommendations in areas of uncertainty. It provides emphatic advice about the need for urgent assessment and treatment of patients with neutropenic sepsis but also provides guidelines for the well patient for whom treatment strategies could be modified. It includes the whole of the patient pathway and takes account of the patient and carer role at each juncture."

Anne Higgins Haemato-oncology Clinical Nurse Specialist, South West London Cancer Network Lead Chemotherapy Nurse and member of the guideline development group, said: "I was very pleased to be involved in the development of this new guideline, which aims to provide healthcare professionals in England and Wales a standardised pathway of care for cancer patients who are at risk of developing neutropenic sepsis. The guideline provides a comprehensive structure for clinical management, with particular focus on investigations, risk stratification and appropriate antibiotics prior to determining the causative pathogens. There is also an emphasis on the provision of information and support to patients and carers. I hope this will be a useful tool for healthcare professionals to deliver excellent care to cancer patients to reduce the risk of neutropenic sepsis, to manage it efficiently and cost effectively."

Rachel Drew, patient and carer member on the guideline development group, said: "From my perspective as someone who has experienced numerous episodes of neutropenic sepsis as the result of treatment for cancer, the guideline's emphasis on the importance of ensuring early recognition of neutropenic sepsis in the community by providing patients with information, and facilitating prompt access to appropriate medical services are key. As many patients will develop neutropenic sepsis at home, away from immediate medical support, the recommendations for both patients and health care professionals on what to do in the period before they come into contact with the oncology team are an essential component of the guideline.

"Furthermore, recommendations for prophylaxis to prevent neutropenic sepsis, and guidance on when treatment can be offered as an outpatient rather than an inpatient, may help to reduce the length of hospital stays or negate the need for admission at all, thus affording many patients more time at home. Given the nature of anti-cancer treatment, this time at home can be invaluable for both patients and their families."

ENDS

Notes to Editors

References

1. Validated risk scoring systems include the Multinational Association for Supportive Care in Cancer (MASCC) risk index for adults (aged 18 years andover) (Klastersky J, Paesmans M, Rubenstein EB et al. [2000] The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients [Journal of Clinical Oncology 18: 3038-51]) andthe modified Alexander rule for children (aged under 18) (Dommett R, Geary J,
Freeman S et al. [2009] Successful introduction and audit of a step-down oral antibiotic strategy for low risk paediatric febrile neutropaenia in a UK, multicentre, shared care setting [European Journal of Cancer 45: 2843-9]).

About the guideline

1. The guideline on the prevention and management of neutropenic sepsis in cancer patients is available from the NICE website (from 19 September) at: cg151 An embargoed copy is available from the NICE press office on request.

About NICE

2. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

3. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

4. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
• Commissioning Outcomes Framework - NICE develops the potential indicators for the COF, the scheme starting in 2013, which will help measure the health outcomes and quality of care commissioned by Clinical Commissioning Groups.

5. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates high quality guidance and evidence-based information to help professionals deliver the best patient care through NHS Evidence.