Febrile Neutropenia 🌡️
UK on-call neutropenic sepsis (febrile neutropenia) aligned to NICE CG151: treat immediately, piperacillin with tazobactam monotherapy, MASCC risk assessment within 24 hours, and when to stop or discharge.
📖 Definition (NICE CG151)
- NICE uses the term neutropenic sepsis. Diagnose it in people having anticancer treatment whose neutrophil count is 0.5 × 10⁹/L or lower, and who have either a temperature higher than 38°C, or other signs or symptoms consistent with clinically significant sepsis.
- Suspect it in anyone on anticancer treatment who becomes unwell, including without a high fever. Refer immediately to secondary or tertiary care.
- Anticancer treatment includes chemotherapy and radiotherapy given with intent to reduce cancer cells.
- Confirm your Trust acute oncology / febrile neutropenia protocol. This topic follows NICE CG151 and does not replace local microbiology or allergy rules.
⚡ Immediate actions
- Treat suspected neutropenic sepsis as an acute medical emergency. Offer empiric antibiotics immediately. Do not wait for the neutrophil count if the history is of anticancer treatment and the patient is unwell.
- ABCDE, lactate, and your Trust suspected-sepsis pathway (see Sepsis). Call acute oncology / haematology early.
- Do not delay the first dose of antibiotics for imaging, a full septic screen, or risk scoring.
🔍 Initial assessment (NICE)
- History and examination: chemotherapy timing, G-CSF, antimicrobial prophylaxis, lines, mucositis, chest, abdomen, perineum, skin, CNS, and urine.
- Bloods: FBC, kidney and liver function including albumin, CRP, lactate, and blood culture.
- If there is a central venous access device, take an additional peripheral blood culture when clinically feasible.
- Urinalysis in all children aged under 5 years.
- Do not perform a chest X-ray unless clinically indicated.
💊 Empiric antibiotics (NICE)
- Offer beta-lactam monotherapy with piperacillin with tazobactam as initial IV empiric therapy, unless there are patient-specific or local microbiological contraindications. Dose per BNF and Trust protocol.
- Do not offer an aminoglycoside as monotherapy or dual therapy for initial empiric treatment unless there are patient-specific or local microbiological indications.
- Do not offer empiric glycopeptides solely because the patient has a central line, unless there are patient-specific or local microbiological indications.
- Do not remove a central venous access device as part of initial empiric management.
- Penicillin allergy, colonisation with resistant organisms, or Trust outbreak rules: follow local microbiology advice for the alternative.
📊 Risk of septic complications
- Within 24 hours of presentation, a professional competent in managing complications of anticancer treatment should assess the risk of septic complications, using presentation features and a validated risk score.
- NICE names MASCC as an example for adults (typically ≥21 low risk). Use the calculator at the bottom. For children, Trusts may use a paediatric rule such as the modified Alexander score.
- MASCC does not replace immediate antibiotics, senior review, or Trust discharge criteria. Do not independently send someone home on the score alone.
🏠 Low risk
- Consider outpatient antibiotic therapy if confirmed neutropenic sepsis and a low risk of septic complications.
- Take account of social and clinical circumstances. Discuss the need to return to hospital promptly if a problem develops.
- Choice of oral regimen is not specified in CG151. Use the Trust low-risk / acute oncology pathway.
🏥 High risk
- A professional competent in anticancer-treatment complications should review clinical status daily and reassess risk with a validated score.
- Do not switch the initial empiric antibiotics for unresponsive fever unless there is clinical deterioration or a microbiological indication.
- Switch from IV to oral antibiotics after 48 hours of treatment if risk has been reassessed as low by that competent professional using a validated score.
- Offer discharge only after risk has been reassessed as low, social and clinical circumstances have been considered, and the patient knows to return promptly if a problem develops.
⏱️ Duration of empiric antibiotics
- Continue inpatient empiric antibiotic therapy in everyone with unresponsive fever unless an alternative cause of fever is likely.
- Discontinue empiric antibiotics once neutropenic sepsis has responded to treatment, irrespective of neutrophil count.
⚠️ Escalate immediately
- Shock, NEWS2 deterioration, new confusion, respiratory distress, severe abdominal pain, or clinical worsening on antibiotics: senior and critical care review, and involve acute oncology / haematology / microbiology.
- If sepsis high-risk criteria are met, complete your Trust sepsis actions in parallel with this pathway.
🛡️ Prevention (not the acute hour)
- For adults with acute leukaemias, stem cell transplants, or solid tumours in whom neutrophils of 0.5 × 10⁹/L or lower are an anticipated consequence of chemotherapy, NICE offers fluoroquinolone prophylaxis during the expected period of neutropenia only. Follow MHRA fluoroquinolone safety advice. Confirm the Trust protocol before starting or stopping prophylaxis on call.
- Do not routinely offer G-CSF to prevent neutropenic sepsis in adults receiving chemotherapy unless G-CSF is an integral part of the regimen or is used to maintain dose intensity.
Related NICE guidance
NICENICE NG253 — Suspected sepsis in people aged 16 or over: recognition, assessment and early management
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
External resources
Educational reference only. Medical disclaimer