Adult Febrile Neutropenia

  • Patient is to be assessed and have antimicrobials administered within 1 hour of presentation

  • Draw samples for culture before administering antibiotic therapy

  • Do not wait for test results before initiating antibiotics

A single oral temperature ≥ 38.3 or ≥ 38.0 sustained over a 1 hour period
AND absolute neutrophil count (ANC) less than or equal to 0.5 x 10⁹ cells/L, OR less than 1 x 10⁹ cells/L with an expected fall to less than 0.5 x 10⁹ cells/L over the next 48 hours.

  1. If patient clinically unstable, notify oncologist on call immediately. If there is no oncologist on call or patient stable, then notify attending oncologist within 24 hrs

  2. Patients, especially stem cell transplant recipients, should be placed in single-patient rooms if possible

  3. Notify Oncology Clinical Trials of patient admission if patient enrolled in a trial

Treatment Criteria & Considerations

  • Vital signs (temperature, respiratory rate, blood pressure, and pulse) and oxygen saturation via pulse oximetry at presentation and as needed based on patient’s condition

  • Intake and output if patient initiated on IV therapy

  • Blood cultures

    • One from each lumen of a venous access device if present and one from a peripheral site
    • Two from different peripheral sites if no venous access device is present
  • Urine culture and urinalysis

  • Sputum Culture, only if patient has respiratory symptoms and can cough deeply to produce

  • CBC with differential, ALT, total bilirubin, ALK Phos, LDH, electrolytes, bicarb, serum creatinine, PT/INR (if patient is on warfarin)

  • Chest X-ray (PA and Lateral)

Also consider:

  • Nasopharyngeal swab for influenza/RSV/COVID-19

  • Lactate

  • Additional imaging or laboratory investigations as per clinical assessment

Consider antibiotic history, recent culture results and exposure to prophylactic antimicrobials when selecting empiric therapy.

If febrile neutropenia, then proceed to risk stratification to guide empiric therapy and management

Empiric Treatment

Re-evaluation & De-Escalation

Additional Information

  • Low-Risk: 2 to 3 days with appropriate empiric therapy

  • High Risk: 5 days with appropriate empiric therapy

More Information

  1. Freifeld, Alison G, Bow, Eric J, Sepkowitz, Kent A, Boeckh, Michael J, Ito, James I, Mullen, Craig A, Raad, Issam I. Rolston, Kenneth V. Young, Jo-Anne H, Wingard, John R. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2011;52:e56–e93.
  2. Flowers, Christopher R, Seidenfeld, Jerome, Bow, Eric J, Karten, Clare, Gleason, Charise, Hawley, Douglas K, Kuderer, Nicole M, Langston, Amelia A, Marr, Kieren A, Rolston, Kenneth V.I, Ramsey, Scott D. Antimicrobial Prophylaxis and Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy. Journal of Oncology Practice 2011:10.1200/JOP.2012.000815
  3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prevention and Treatment of Cancer-Related Infections, version 2.2020. Available at:
  4. Martire et al. De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome. Eur J Clin Microbiol Infect Dis. 2018 Oct;37(10):1931-1940.