Chemo 8 days ago, now T 38.6 °C, ANC 0.2 — treat as sepsis with an hour on the clock: cultures then piperacillin-tazobactam immediately.
ABCDE
Single T ≥38.3 °C (or ≥38.0 ×1 h) + ANC <0.5 = emergency; cultures ×2 + CXR + urine, then antipseudomonal β-lactam within 1 h; vancomycin only for specific indications.
Define + act fast: ANC <0.5×10⁹/L + single T ≥38.3 °C or ≥38.0 °C sustained 1 h — mortality rises with every hour of antibiotic delay
Workup in 30 min: blood cultures ×2 (peripheral + each line lumen), CXR, urinalysis, lactate, FBC/U&E/LFT/CRP — do not delay antibiotics for results
Empiric antibiotics within 1 h: piperacillin-tazobactam 4.5 g IV q6–8 h (or cefepime 2 g q8h / meropenem 1 g q8h if severe/ESBL risk)
Add vancomycin ONLY if: suspected line infection, skin/soft-tissue infection, hypotension/septic shock, MRSA colonisation, or severe mucositis — stop at 48 h if cultures negative
Risk-stratify: low risk (MASCC ≥21, solid tumour, stable) → oral ciprofloxacin + co-amoxiclav outpatient possible; high risk → admit, G-CSF if shock/pneumonia/fungal
Persistent fever >72–96 h: with ANC still <0.5 → add antifungal (caspofungin 70 mg then 50 mg, or voriconazole); daily exam: lines, perianal, mouth, lungs
Order set
- Blood cultures ×2 (peripheral + line)
- Piperacillin-tazobactam 4.5 g IV STAT
- Lactate, FBC, U&E, LFT, CRP
- CXR + urinalysis
- G-CSF if shock/pneumonia/high-risk
- Antifungal if febrile >96 h
- Standard food hygiene (neutropenic diet NOT recommended — NICE CG151/IDSA); single room + hand hygiene
Monitor
- q4 hTemperature curve, BP — neutropenic sepsis hides signs
- DailyFBC (ANC trajectory), exam: line sites, mouth, perianal, chest
- 48 hReview cultures — stop vancomycin if negative
- 96 hFever persists + ANC <0.5 → antifungal decision
Escalate / ICU
- Hypotension or lactate ≥2 — septic shock pathway
- Pneumonia or typhlitis (RLQ pain) on imaging
- Fever >96 h on broad-spectrum
- ANC expected <0.1 ×7+ days
Criteria
AntibioticsAntipseudomonal within 1 h — every patient
VancomycinLine infection, skin/soft tissue, shock, MRSA, mucositis only
OutpatientMASCC ≥21 + solid tumour + stable + support at home
AntifungalFever >96 h with persistent neutropenia
Never
- Delay antibiotics for the neutrophil count or imaging results
- Add vancomycin routinely — no benefit, real toxicity
- Give PRBC or platelets for stable numbers without thresholds (platelets <10, or <50 if bleeding) — discuss each
Key
- Door-to-needle <1 h is the quality standard — treat before the count returns
- Gram-negative rods kill fastest — antipseudomonal cover is non-negotiable
- Documented β-lactam allergy: ciprofloxacin + clindamycin, or aztreonam + vancomycin
- No fever ≠ no infection: neutropenic patients may present hypothermic or just 'unwell'
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- T ≥38.3 or hypothermia with ANC <0.5
- Hypotension, tachycardia, confusion
- Line-site erythema or perianal pain
- New cough/hypoxia — pneumonia progresses fast
Differentials
- Central line infection
- Pneumonia, typhlitis (neutropenic enterocolitis)
- Invasive fungal infection
- Drug fever (less likely early)
Common mistakes
- Rectal examination/suppositories in neutropenia — bacteraemia risk
- Co-amoxiclav alone (no pseudomonal cover)
- Keeping vancomycin beyond 48 h negative cultures
- Forgetting antifungals at 96 h
Disposition & follow-up
Continue IV antibiotics until afebrile ×48 h AND ANC recovering (>0.5); total course per source; oncology notified to adjust next cycle.
💊 Treatment detail — doses & preparation
Piperacillin-tazobactambroad-spectrum β-lactam
Dose4.5 g IV q6–8h (q6h if critically ill); renal adjust
Preparation4.5 g vial in 100 mL NS/D5W over 30 min (extended 4-h infusion if severe sepsis)
MonitorRenal function, Na⁺ load, eosinophilia; de-escalate per cultures at 48–72 h
Vancomycin IVglycopeptide
DoseLoad 25–30 mg/kg (critically ill), then 15–20 mg/kg q8–12h by levels (AUC 400–600)
PreparationDilute to ≤5 mg/mL in NS/D5W; infuse ≥60 min per 500 mg (red-man if fast)
MonitorTrough/AUC before 3rd–4th dose, creatinine, ototoxicity
Caspofunginechinocandin antifungal
Dose70 mg IV load then 50 mg OD (persistent febrile neutropenia/invasive candida)
Preparation70/50 mg vial reconstitute + dilute in 250 mL NS over 1 h
MonitorLFTs; no renal adjustment
Filgrastim (G-CSF)colony-stimulating factor
Dose5 mcg/kg SC OD (febrile neutropenia with shock/pneumonia/fungal, or prophylaxis)
Preparation300 mcg pre-filled syringe SC
MonitorBone pain, splenomegaly; stop when ANC recovered
📖 NICE/IDSA febrile neutropenia + textbook Ch.40Reviewed July 2026