Febrile Neutropenia Management (ASCO/IDSA 2018)

Algorithm Steps

1. ▶

   Start

   Fever + Neutropenia

   Temp ≥38.3°C or ≥38.0°C sustained 1h + ANC <500 or expected to fall <500

   1. ●

      Action

      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
      1. ⚠

         Warning

         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
         1. ●

            Action

            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
            1. ◆

               Decision

               Risk Stratification

               MASCC score and clinical factors

               1. ●

                  Action

                  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
                  1. ◆

                     Decision

                     Reassess at 48-72 Hours

                     Evaluate response to therapy

                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           Resolution of Neutropenic Fever

                           ANC recovery + infection cleared

                     2. ●

                        Action

                        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
               2. ●

                  Action

                  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