Neutropenic fever in an adult with cancer
Temp 38.0°C or higher and neutrophils below 0.5 x 10^9/L, or below 1.0 and expected to fall below 0.5 within 48 h. Adults only; children: use a paediatric pathway.
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Hematology & OncologyEmergency
Febrile Neutropenia in Adults with Cancer
Febrile Neutropenia in Adults with Cancer: Neutropenic fever in an adult with cancer → Medical emergency: treat before results → Immediate assessment an...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Warning Medical emergency: treat before results
Any unwell patient after recent anticancer therapy: start treatment now, without waiting for the blood count.
- Sepsis can occur without fever: older age, corticosteroids, tocilizumab
- Afebrile neutropenic patient with new signs of infection: treat as high risk
- Adults only. Children: use a paediatric fever and neutropenia pathway
03Action Immediate assessment and cultures
Oxygen and IV access. Assess for sepsis with the local sepsis pathway (hypotension, lactate above 2 mmol/L, altered mental state, organ dysfunction). Tests must not delay antibiotics.
- Blood cultures before antibiotics: at least 2 sets, 1 from each CVAD lumen plus 1 peripheral (no CVAD: 2 peripheral sites)
- FBC with differential, UEC, LFTs, lactate (if above 2 mmol/L, repeat in 2 h)
- Urine culture; sputum, respiratory swabs, stool, CVAD exit site and wound swabs as indicated
- Chest X-ray if respiratory signs; CT as indicated
- Observations every 30 min for 2 h, then hourly for 4 h; fluid resuscitation if indicated
04Warning Before antibiotics: allergy, resistant organisms, kidney function
Do not delay the first dose. Choose the allergy option in the next step if needed.
- Beta-lactam allergy: check the drug and type (non-severe, anaphylaxis or SCAR); penicillin and cephalosporin rules differ
- ESBL colonisation or other risk of resistant gram-negatives, with sepsis: see sepsis step. CPO colonisation: call infectious diseases now
- Doses are for normal kidney function: adjust later doses for kidney function
05Action IV antibiotics now: within 1 hour
After blood cultures; if cultures are difficult, do not delay antibiotics. Give within 1 h of triage; always within 1 h if sepsis. Adult doses. Stable patients: beta-lactam monotherapy, also if at risk of resistant organisms.
- No penicillin allergy: piperacillin-tazobactam 4.5 g IV 6-hourly OR cefepime 2 g IV 8-hourly
- Non-severe penicillin allergy: cefepime 2 g IV 8-hourly
- Penicillin anaphylaxis: cefepime if non-cross-reactive, OR meropenem 1 g IV 8-hourly
- Severe cutaneous reaction (SCAR): expert advice; aztreonam 1-2 g IV 8-hourly or ciprofloxacin 400 mg IV 8-hourly, plus vancomycin
- Cephalosporin allergy: avoid cefepime if the allergy is to ceftriaxone or cefuroxime (shared side chains); get allergy or infectious diseases advice
- Abdominal or perineal source, including neutropenic enterocolitis, on cefepime, aztreonam or ciprofloxacin: add metronidazole 500 mg IV 12-hourly
- After the first dose: consider extended or continuous beta-lactam infusion
06Action Sepsis or septic shock: escalate now
Only for systemic compromise. Resuscitate per the local sepsis pathway and call ICU early.
- Septic shock, or selected sepsis: add gentamicin 6-7 mg/kg IV once daily (lean body weight; max 680 mg)
- Known ESBL colonisation or other risk of resistant gram-negatives (local policy), with sepsis: add the aminoglycoside, OR change to meropenem 1 g IV 8-hourly
- Kidney impairment: aminoglycoside and vancomycin need dose adjustment and levels
- Still unstable after first doses: broaden to cover resistant gram-negatives, gram-positives, anaerobes and fungi; ID advice
07Action Vancomycin: only for a specific indication
Not routine. Give the beta-lactam first.
- Gram-positive organism in blood culture (pending identification)
- Severe penicillin allergy (SCAR) on aztreonam or ciprofloxacin: always add vancomycin
- Suspected CVAD infection, skin or soft tissue infection, pneumonia or severe mucositis with sepsis; haemodynamic instability; MRSA colonisation with sepsis
- Adult dose: 25-30 mg/kg IV loading (max 3 g), then 15-20 mg/kg (max 2 g) 12-hourly; use therapeutic drug monitoring
- Review at 48 h: stop if no gram-positive infection is found
- Known VRE colonisation with sepsis: ask infectious diseases (teicoplanin, daptomycin or linezolid)
08Action Assess risk: MASCC score
Maximum 26 points. 21 or more = low risk. 20 or less = high risk.
- Burden of illness: no or mild symptoms 5; moderate symptoms 3; severe 0
- No hypotension (systolic BP above 90 mmHg): 5
- No COPD: 4
- Solid tumour, or haematological cancer with no previous fungal infection: 4
- No dehydration needing IV fluids: 3
- Outpatient at onset of fever: 3
- Age under 60 years: 2
09Decision High risk?
Yes if MASCC 20 or less, OR any of: sepsis or haemodynamic instability; acute leukaemia or stem cell transplant; neutropenia expected over 7 days; neutrophils below 0.1 x 10^9/L; pneumonia, hypoxaemia or chronic lung disease; CVAD or tunnel infection; new abdominal pain, vomiting or diarrhoea; mucositis or enterocolitis; new neurological change; ALT or AST over 5 times normal; creatinine clearance below 30 mL/min; other major comorbidity.
- If Yes
- Yes: high risk
10Action High risk: admit and continue IV antibiotics
Inpatient IV therapy. Review at least daily.
- Haematology or oncology team, with infectious diseases input
- Adjust antibiotics to culture results and site of infection
- ICU review if unstable
- CVAD infection: remove the line for S. aureus, Pseudomonas or fungal infection, tunnel or port infection, instability, or bacteraemia after 72 h of treatment
11Decision Reassess at 48-72 h: afebrile and stable?
Review cultures, clinical course and neutrophil count.
- If Yes
12Action Afebrile and stable: continue or narrow
Decide the plan with infectious diseases.
- Documented infection: treat for the site and organism, at least until neutrophils reach 0.5 x 10^9/L
- Unexplained fever: continue until afebrile at least 2 days and neutrophils above 0.5 x 10^9/L and rising
- De-escalation, IV-to-oral switch or stopping before neutrophil recovery: only with infectious diseases advice
- Vancomycin: stop at 48 h if no gram-positive infection
- Fever recurs: repeat cultures and re-evaluate as in the not-afebrile step; consider fungal infection if neutropenia persists
13Outcome Resolution of neutropenic fever
Neutrophil recovery and infection treated.
If No14Action Not afebrile or not stable: re-evaluate
Persistent fever alone in a stable patient rarely needs a change of antibiotics.
- Unstable or worse: broaden cover and call ICU (see sepsis step)
- Repeat blood cultures; examine CVAD, skin, perianal area, lungs and abdomen
- Imaging as indicated, for example CT chest
- Do not add vancomycin for fever alone
- Change antibiotics for a documented infection or organism
15Action Fever persists or recurs at 4-7 days: check for fungal infection
Only high-risk patients with neutropenia expected to last over 7 days. Plan with haematology and infectious diseases.
- CT chest (and sinuses if symptoms); serum galactomannan or beta-D-glucan where available
- Start empiric antifungal therapy, or pre-emptive therapy if work-up is positive
- Empiric options: liposomal amphotericin B, caspofungin or voriconazole; choose and dose with infectious diseases and local protocol
- On mould-active azole prophylaxis: switch to a different class of IV mould-active antifungal
- Low-risk patients: routine empiric antifungal therapy is not recommended
- Path rejoins step 13Shared downstream outcome
If No- No: low risk
16Action Low risk: outpatient oral antibiotics may be possible
Only if MASCC 21 or more, none of the high-risk features in the previous step (for example acute leukaemia, stem cell transplant, neutropenia expected over 7 days, CVAD infection, creatinine clearance below 30 mL/min) and every outpatient criterion met; otherwise admit. On fluoroquinolone prophylaxis: no oral fluoroquinolone; admit for IV therapy.
- First IV dose in hospital; observe for at least 4 h before discharge
- Criteria: 1 h or less from hospital, carer at home 24 h a day, telephone, can take oral drugs, treating team agrees
- Oral (adult): amoxicillin-clavulanate 875/125 mg 12-hourly (or 500/125 mg 8-hourly) plus ciprofloxacin 750 mg 12-hourly
- Any penicillin allergy (oral): clindamycin 600 mg 8-hourly plus ciprofloxacin 750 mg 12-hourly
- Allergy to cefalexin or cefaclor, or unknown cephalosporin: clindamycin plus ciprofloxacin (not amoxicillin-clavulanate). Anaphylaxis to another cephalosporin: expert advice
- Ciprofloxacin 500 mg 12-hourly may suit weight 40 kg or less or kidney impairment
- Solid tumour: CISNE score can add risk information
17Action Low risk at home: daily review
Readmit and treat as high risk if the patient does not settle.
- Readmit: fever at 48-72 h or recurs, new signs of infection, cannot take oral drugs, positive blood culture or worse
- Continue oral antibiotics at least 24-48 h after fever resolves and neutrophils recover
- Give the patient written return advice and a 24 h contact number
- Path rejoins step 13Shared downstream outcome
Guideline Source
Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer 2024: Initial management (Douglas et al.)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Children and adolescents: use a paediatric fever and neutropenia guideline.
- Doses assume normal kidney and liver function. Follow the local antibiogram and antimicrobial stewardship policy.
- Stem cell transplant, CAR-T therapy and CPO colonisation need a specialist-led plan.
- Antimicrobial prophylaxis and G-CSF use are not covered.
Contraindicated Populations
Children and adolescents (use a paediatric fever and neutropenia guideline)
Applicable Regions
AUNZUSEUGlobal
AU: Follows the 2024 Australasian consensus guidelines as adapted in eviQ ID 123 (V7, July 2026) and eTG Antibiotic. Fever is a single temperature of 38.0°C or higher.
EU: ECIL guidance may differ in some recommendations.
US: IDSA 2010 and ASCO/IDSA 2018 define fever as one oral temperature of 38.3°C or higher, or 38.0°C or higher sustained over 1 h. They advise the first dose within 1 h of triage for all patients.
Version 2Next review: 2027-09-30
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Absolute neutrophil count from CBC for neutropenia grading
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Frequently Asked Questions
What is the Febrile Neutropenia in Adults with Cancer?
The Febrile Neutropenia in Adults with Cancer is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer 2024: Initial management (Douglas et al.).
What guideline is the Febrile Neutropenia in Adults with Cancer based on?
This algorithm is based on Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer 2024: Initial management (Douglas et al.) (DOI: 10.1111/imj.70248).
What are the limitations of the Febrile Neutropenia in Adults with Cancer?
Known limitations include: Adults only. Children and adolescents: use a paediatric fever and neutropenia guideline.; Doses assume normal kidney and liver function. Follow the local antibiogram and antimicrobial stewardship policy.; Stem cell transplant, CAR-T therapy and CPO colonisation need a specialist-led plan.; Antimicrobial prophylaxis and G-CSF use are not covered.. Individual patient factors may require deviation from these recommendations.
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