Fever + Neutropenia
Temp ≥38.3°C or ≥38.0°C sustained 1h + ANC <500 or expected to fall <500
All Pathways
Hematology & OncologyEmergency
Febrile Neutropenia Management (ASCO/IDSA 2018)
Febrile Neutropenia Management (ASCO/IDSA 2018): Fever + Neutropenia → Immediate Evaluation → Start Empiric Antibiotics STAT → Calculate MASCC Score → R...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action Immediate Evaluation
Within 15 minutes of presentation
- Vital signs, oxygen saturation
- Blood cultures (2 sets, including central line if present)
- CBC with differential
- Comprehensive metabolic panel
- Urinalysis and culture
- Chest X-ray if respiratory symptoms
- Site-specific cultures as indicated
03Warning Start Empiric Antibiotics STAT
Within 60 minutes of presentation
- Anti-pseudomonal beta-lactam monotherapy preferred:
- Cefepime 2g IV q8h, OR
- Piperacillin-tazobactam 4.5g IV q6h, OR
- Meropenem 1g IV q8h (if ESBL risk)
- Add vancomycin if: MRSA risk, catheter infection, skin/soft tissue, severe mucositis, hemodynamic instability
04Action Calculate MASCC Score
Multinational Association for Supportive Care in Cancer
- Burden of illness: None/mild (5) vs Moderate (3) vs Severe (0)
- No hypotension (SBP ≥90): 5
- No COPD: 4
- Solid tumor or no prior fungal infection: 4
- No dehydration: 3
- Outpatient at fever onset: 3
- Age <60: 2
- HIGH RISK: Score <21 | LOW RISK: Score ≥21
05Decision Risk Stratification
MASCC score and clinical factors
06Action High Risk (MASCC <21)
Inpatient IV antibiotics required
- Admit to hospital
- Continue IV empiric antibiotics
- Monitor closely for complications
- Consider ICU if unstable
- Consult infectious disease
07Decision Reassess at 48-72 Hours
Evaluate response to therapy
08Action Responding
Afebrile, clinically improving
- Continue current regimen
- Can narrow based on culture results
- Total duration: 7-14 days or until ANC recovery
- Consider oral step-down if stable
09Outcome Resolution of Neutropenic Fever
ANC recovery + infection cleared
10Action Not Responding
Persistent fever, clinical worsening
- Repeat cultures, imaging as indicated
- Broaden antibiotics (add vancomycin if not on)
- Consider antifungal coverage if fever >4-7 days
- Antifungal: Caspofungin, voriconazole, or ampho B
- CT chest/sinuses for occult fungal infection
- Path rejoins step 07Shared downstream outcome
11Action Low Risk (MASCC ≥21)
Outpatient therapy may be considered
- Must have: reliable caregiver, phone access, proximity to hospital
- Oral therapy: Ciprofloxacin 750mg q12h + Amoxicillin-clavulanate 875mg q12h
- Alternative: Levofloxacin 750mg daily monotherapy
- Daily follow-up required
- Return precautions: Fever persists, unable to take PO, clinical worsening
- Path rejoins step 07Shared downstream outcome
Guideline Source
Outpatient Management of Fever and Neutropenia in Adults: ASCO/IDSA Clinical Practice Guideline Update
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- MASCC score has limitations in specific populations
- Local antibiogram should guide empiric therapy
- Does not address antifungal prophylaxis in detail
- Outpatient management requires close follow-up capability
Applicable Regions
USEUGlobal
EU: ECIL guidelines may differ in some recommendations
US: NCCN guidelines also commonly referenced
Version 1Next review: 2027-01-01
Next steps
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Absolute Neutrophil Count (ANC)
Absolute neutrophil count from CBC for neutropenia grading
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Frequently Asked Questions
What is the Febrile Neutropenia Management (ASCO/IDSA 2018)?
The Febrile Neutropenia Management (ASCO/IDSA 2018) is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on Outpatient Management of Fever and Neutropenia in Adults: ASCO/IDSA Clinical Practice Guideline Update.
What guideline is the Febrile Neutropenia Management (ASCO/IDSA 2018) based on?
This algorithm is based on Outpatient Management of Fever and Neutropenia in Adults: ASCO/IDSA Clinical Practice Guideline Update (DOI: 10.1200/JCO.2017.77.6211).
What are the limitations of the Febrile Neutropenia Management (ASCO/IDSA 2018)?
Known limitations include: MASCC score has limitations in specific populations; Local antibiogram should guide empiric therapy; Does not address antifungal prophylaxis in detail; Outpatient management requires close follow-up capability. Individual patient factors may require deviation from these recommendations.
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