Definition of neutropenia and fever

• Diagnose neutropenic sepsis in patients having anticancer treatment whose neutrophil count is 0.5 × 10⁹ per litre or lower and who have either:

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  a temperature higher than 38°C or

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  other signs or symptoms consistent with clinically significant sepsis.

Information and support for patients and carers

Training for healthcare professionals

• Healthcare professionals and staff who come into contact with patients having anticancer treatment should be provided with training on neutropenic sepsis. The training should be tailored according to the type of contact.

Signs and symptoms that necessitate referral to secondary/tertiary care

• Suspect neutropenic sepsis in patients having anticancer treatment who become unwell.
• Refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care.

Emergency assessment in secondary/tertiary care

Assessing the patient's risk of septic complications

• A healthcare professional with competence in managing complications of anticancer treatment should assess the patient's risk of septic complications within 24 hours of presentation to secondary or tertiary care, basing the risk assessment on presentation features and using a validated risk scoring system⁴.

Preventing the septic complications of anticancer treatment

• For adult patients (aged 18 years and older) with acute leukaemias, stem cell transplants or solid tumours in whom significant neutropenia (neutrophil count 0.5 × 10⁹ per litre or lower) is an anticipated consequence of chemotherapy, offer prophylaxis with a fluoroquinolone during the expected period of neutropenia only.
• Rates of antibiotic resistance and infection patterns should be monitored in treatment facilities where patients are having fluoroquinolones for the prophylaxis of neutropenic sepsis⁵.
• Do not routinely offer granulocyte-colony stimulating factor (G-CSF) for the prevention of neutropenic sepsis in adults receiving chemotherapy unless they are receiving G-CSF as an integral part of the chemotherapy regimen or in order to maintain dose intensity.

Timing of initial antibiotic treatment

• Treat suspected neutropenic sepsis as an acute medical emergency and offer empiric antibiotic therapy immediately.

Empiric intravenous antibiotic monotherapy or intravenous antibiotic dual therapy

• Offer beta lactam monotherapy with piperacillin with tazobactam⁶ as initial empiric antibiotic therapy to patients with suspected neutropenic sepsis who need intravenous treatment unless there are patient-specific or local microbiological contraindications.
• Do not offer an aminoglycoside, either as monotherapy or in dual therapy, for the initial empiric treatment of suspected neutropenic sepsis unless there are patient-specific or local microbiological indications.

Empiric glycopeptide antibiotics in patients with central venous access devices

• Do not offer empiric glycopeptide antibiotics to patients with suspected neutropenic sepsis who have central venous access devices unless there are patient-specific or local microbiological indications.

Indications for removing central venous access devices

• Do not remove central venous access devices as part of the initial empiric management of suspected neutropenic sepsis.

Inpatient versus outpatient management strategies

• Consider outpatient antibiotic therapy for patients with confirmed neutropenic sepsis and a low risk of developing septic complications, taking into account the patient's social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops.

Changing the initial empiric treatment in unresponsive fever

• For patients with confirmed neutropenic sepsis and a high risk of developing septic complications, a healthcare professional with competence in managing complications of anticancer treatment should daily:

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  review the patient's clinical status

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  reassess the patient's risk of septic complications using a validated risk scoring system⁷

• Do not switch initial empiric antibiotics in patients with unresponsive fever unless there is clinical deterioration or a microbiological indication.

Switching from intravenous to oral antibiotic treatment

• Switch from intravenous to oral antibiotic therapy after 48 hours of treatment in patients whose risk of developing septic complications has been reassessed as low by a healthcare professional with competence in managing complications of anticancer treatment using a validated risk scoring system⁷.

Duration of inpatient care

• Offer discharge to patients having empiric antibiotic therapy for neutropenic sepsis only after:

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  the patient's risk of developing septic complications has been reassessed as low by a healthcare professional with competence in managing complications of anticancer treatment using a validated risk scoring system⁷ and

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  taking into account the patient's social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops.

Duration of empiric antibiotic treatment

• Continue inpatient empiric antibiotic therapy in all patients who have unresponsive fever unless an alternative cause of fever is likely.
• Discontinue empiric antibiotic therapy in patients whose neutropenic sepsis has responded to treatment, irrespective of neutrophil count.