Bacterial Sepsis in High-Grade Non-Hodgkin's Lymphoma

Primary Sources of Infection

Endobronchial tumor involvement may cause recurrent postobstructive pneumonias, and direct tumor invasion through colonic mucosa can lead to local abscess formation and sepsis by enteric flora, abdominal tumors may obstruct the genitourinary tract, predisposing patients to pyelonephritis, and tumor necrosis can form a nidus for infection, hematologic malignancies may cause leukopenia from marrow infiltration, and multiple prior chemotherapy regimens significantly increase infection risk in patients with high-grade non-Hodgkin's lymphoma 1
Clostridium difficile colitis is a significant concern in heavily treated patients with high-grade non-Hodgkin's lymphoma 2

Device-related infections are particularly frequent in immunocompromised patients, and any artificial device (e.g., venous catheter) should be carefully checked for signs of infection 3

Obtain at least 2 sets of blood cultures before starting antimicrobial therapy, and perform appropriate imaging studies promptly to identify the source of infection, and administer effective intravenous antimicrobials within the first hour of recognition of septic shock in patients with high-grade non-Hodgkin's lymphoma 4
Initial empiric anti-infective therapy should include one or more drugs active against all likely pathogens, consider combination therapy for neutropenic patients with severe sepsis, for Pseudomonas aeruginosa bacteremia, use combination therapy with an extended-spectrum β-lactam and either an aminoglycoside or a fluoroquinolone, and reassess antimicrobial regimen daily for potential de-escalation 5

Consider antimicrobial prophylaxis in high-risk patients, and consider PCP prophylaxis in patients receiving corticosteroids equivalent to prednisone 20 mg/day for ≥4 weeks 7