A 44-year-old woman presents with a temperature of 38.1°C, 3 days after starting cycle 2 of chemotherapy for advanced colorectal cancer. She had T3a rectal cancer resected 8 weeks ago with an end colostomy.

She feels well, with normal observations. Examination shows moist, oral mucosa, a clear chest, a soft, non-tender abdomen, and a pink, warm colostomy producing type 5 stool. No focal neurological signs, meningism, rash, or cellulitis are present.

Investigations:

Urine dip: Clear
Beta-hCG: Negative
Chest X-ray: Unremarkable
  
 

| Serum | Result | Reference Range |
| ------------------------------------ | ------ | ------------------- |
| Haemoglobin | 95 | 115-155 mg/dL |
| White Cell Count | 2.1 | 3.0 - 10.0 x 10⁹ /L |
| Platelets | 160 | 150 - 400 x 10⁹/L |
| Neutrophils | 0.5 | 2.0 - 7.5 x 10⁹ /L |
| Sodium | 135 | 135 - 146 mmol/L |
| Potassium | 3.6 | 3.5 - 5.3 mmol/L |
| Urea | 2.8 | 2.5 - 7.8 mmol/L |
| Creatinine | 45 | 60 - 120 µmol/L |
| eGFR | >90 | \> 60 mL/min/1.73m2 |
| C reactive protein | 25 | < 5 mg/L |
| Lactate | 1.2 | 0.20-1.80 mmol/L |
  
 

Which of the following is the best next step in the management of this patient?

Options:
explanation: The main concern in patients on chemotherapy with pyrexia is neutropenic sepsis. This is defined as a temperature of greater than 38.0°C, OR any symptoms and/or signs of sepsis, in a person with absolute neutrophil count of 0.5 x 10⁹/L or lower.
 

 These patients are severely immunosuppressed and cannot mount the normal immune response to infection that others can. They can look and feel completely well for some time, with relatively normal observations, before rapidly becoming unwell and deteriorating. Low threshold are needed to treat aggressively early and take cultures from any possible source to help guide choice of step-down antibiotics
name: IV broad-spectrum antibiotics
label: a
answer: yes
explanation: This patient has neutropenic sepsis: a temperature of greater than 38.0°C, OR any symptoms and/or signs of sepsis, in a person with absolute neutrophil count of 0.5 x 10⁹/L or lower. They need cultures from possible infection sites and broad spectrum antibiotics as they are at high risk of deteriorating
name: Tranfuse one unit of packed red blood cells
label: d
answer: no
explanation: This patient has neutropenic sepsis: a temperature of greater than 38.0°C, OR any symptoms and/or signs of sepsis, in a person with absolute neutrophil count of 0.5 x 10⁹/L or lower. They are at high risk of deteriorating and so should be admitted for cultures and broad spectrum antibiotics
name: Discharge the patient and provide extensive safety-netting advice to return if develops any signs of infection
label: c
answer: no
explanation: This patient has neutropenic sepsis: a temperature of greater than 38.0°C, OR any symptoms and/or signs of sepsis, in a person with absolute neutrophil count of 0.5 x 10⁹/L or lower. They need cultures from possible infection sites and broad spectrum antibiotics as they are at high risk of deteriorating
name: Admit the patient for observation for 24 hours
label: b
answer: no
explanation: This patient has neutropenic sepsis and are at high risk of deteriorating and so should be admitted for cultures and broad spectrum antibiotics. CT scans can be used to identify the source of the infection, particularly if there any underlying collections, although it is not the first line investigation for determining the source. Cultures should be taken first and cross-sectional imaging to be considered if the source is still not identified despite this and the patient is still symptomatic
name: Urgent CT Chest Abdomen and Pelvis
label: e
answer: no

Correct answer: a

IV broad-spectrum antibiotics

Learning point: Neutropenic sepsis in chemotherapy patients requires immediate IV broad-spectrum antibiotics.