Approach to managing patients with febrile neutropenia

In patients with febrile neutropenia, rapid initiation of broad-spectrum antimicrobials is essential. Consider infection in any unwell patient with neutropenia (neutrophils less than 0.5 × 10⁹/L, or less than 1 × 10⁹/L with a predicted decline to less than 0.5 × 10⁹/L), because fever may not be present, particularly if the patient is elderly or taking corticosteroids.

If febrile neutropenia is suspected in a patient in a general practice or outpatient setting, transfer the patient to hospital urgently.

For the greatest survival benefit, give antibiotics as early as possible. Start antibiotics within 1 hour of the patient presenting to medical care or, for a ward-based patient, developing febrile neutropenia; if there are signs of sepsis or septic shock (see here for definitions in adults and here for definitions in children), start antibiotics within 30 minutes. See Early intervention for sepsis or septic shock for nonantibiotic management of sepsis or septic shock.

Obtain blood samples for culture before administering antibiotics. In adults, collect two sets of samples (ie four bottles) from separate sites (a peripheral site and the access device, for patients with a central venous access device). A single, smaller-volume sample is appropriate for young children.

Consider removing intravascular devices—seek expert haematology or oncology advice.