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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Febrile neutropenia

Infectious diseases, microbiology and sexual health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Neutropenic sepsis

A patient receiving anticancer treatment with neutrophils at or below 0.5 × 10⁹/L and temperature above 38°C, or any clinically significant sepsis feature, has a time-critical emergency.

Action: Use ABCDE, obtain blood cultures and baseline tests immediately, and give the locally approved empirical intravenous antibiotic without waiting for the differential count, imaging or microbiology when sampling would cause delay. Escalate shock, hypoxaemia or organ dysfunction to critical care early.

Synopsis

Recognise infection despite attenuated inflammation, deliver immediate empirical antibacterial treatment, recover useful microbiology, and respond intelligently to instability, resistance risk and persistent fever.

  • Treat suspected neutropenic sepsis as an acute medical emergency; a normal temperature does not exclude dangerous infection when corticosteroids, antipyretics or profound immune failure blunt fever.
  • NICE uses neutrophils 0.5 × 10⁹/L or lower plus temperature above 38°C or another clinically significant sepsis feature in a patient receiving anticancer treatment.
  • Take peripheral blood cultures and, where feasible, a separate culture from every relevant central-line lumen before antibiotics, but never sacrifice prompt treatment to complete sampling.
  • Piperacillin with tazobactam is NICE-supported initial beta-lactam monotherapy when intravenous treatment is required, unless allergy, previous microbiology or local resistance makes it unsuitable.
  • Do not add an aminoglycoside or glycopeptide routinely; use additional cover for a defined clinical, microbiological or local-epidemiological indication.
  • Reassess physiology, source, cultures and antimicrobial exposure repeatedly; narrowing, oral switch or discharge depends on validated risk assessment and reliable follow-up rather than the temperature alone.
  • Persistent fever is a decision point, not an automatic diagnosis: repeat examination, seek an occult focus and assess invasive fungal risk before starting a mould-active agent.
  • The infectious-diseases emphasis is organism recovery, resistance-informed empirical choice and targeted escalation; chemotherapy scheduling and marrow-support decisions remain with acute oncology or haematology.

Key red flags

Hypotension, new confusion, tachypnoea, mottling, oliguria, rising lactate or a new oxygen requirement indicates high-risk sepsis even when fever is absent.

Severe abdominal pain, distension, diarrhoea, guarding or gastrointestinal bleeding may represent neutropenic enterocolitis, perforation or Clostridioides difficile infection.

Pleuritic pain, haemoptysis, nasal eschar, focal neurology or fever persisting during broad antibacterial therapy raises concern for invasive mould disease.

Pain out of proportion, rapidly spreading erythema, bullae or crepitus requires immediate surgical review for necrotising soft-tissue infection.

A tunnelled-line exit-site change, rigors during line use or unequal paired-culture time to positivity may signal catheter-related bloodstream infection.

Previous colonisation with a carbapenemase producer, resistant Gram-negative isolate or recent overseas healthcare changes empirical cover and requires immediate microbiology ownership.

Fever or hypothermia

A single temperature above 38°C meets the NICE temperature element; hypothermia, rigors or an unexplained temperature trend can be equally concerning in a profoundly immunosuppressed patient.

Physiological deterioration

New tachycardia, breathlessness, confusion, weakness, oliguria or poor perfusion warrants emergency treatment even before fever or the current neutrophil count is known.

Investigation priorities

01
Immediate blood culturesFirst step

Recover bloodstream pathogens and distinguish peripheral from catheter-associated infection before antimicrobial exposure reduces yield.

02
First-line severity panelFirst line

Confirm cytopenias, detect organ dysfunction and provide baselines for antimicrobial dosing and sepsis reassessment.

Management branches

FIRST HOURTreat before certainty

Fever, sepsis physiology or concerning focal symptoms occur during or soon after anticancer treatment.

  1. Perform ABCDE, establish intravenous access, measure lactate and assess shock, hypoxaemia, abdominal catastrophe and line or soft-tissue source.
  2. Take paired blood cultures and baseline bloods immediately while a second clinician prepares empirical treatment; do not await a neutrophil result.
  3. Give piperacillin with tazobactam through the local neutropenic-sepsis protocol unless allergy, resistance history or a specific focus requires an approved alternative.
  4. Provide balanced fluid, oxygen and vasopressor or critical-care support according to physiology, with urgent source-control review where indicated.

Key medicines

Piperacillin with tazobactamGive 4.5 g intravenously every 6 hours for febrile neutropenia in an adult with normal renal function, using the stocked product instructions and local infusion policy.Check the immediate-allergy phenotype, renal function, sodium load and previous resistant isolates; adjust the interval in renal impairment and review for cytopenia, hepatic effects and Clostridioides difficile infection.
Severe beta-lactam-allergy regimenUse the hospital's named severe immediate beta-lactam-allergy neutropenic-sepsis protocol, selected urgently with microbiology from the allergy phenotype, previous isolates, renal function and suspected source.There is no single nationally correct substitute; aztreonam-based combinations may leave important gaps, while carbapenem cross-reactivity and glycopeptide need require individual assessment.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • Recommendations | Neutropenic sepsis: prevention and management in people with cancer | Guidance | NICE
  • Neutropenic sepsis | Quality standards | NICE
  • Piperacillin/Tazobactam 4 g/0.5 g powder for solution for infusion - Summary of Product Characteristics (SmPC) - (emc) | 100194
  • Start Smart - Then Focus: antimicrobial stewardship toolkit for inpatient care settings
  • British Society for Medical Mycology best practice recommendations for the diagnosis of serious fungal diseases

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Abdominal syndrome

Right-sided pain, distension, diarrhoea or bleeding during profound neutropenia suggests enterocolitis; peritonism or shock may indicate necrosis or perforation.

Prolonged-fever phenotype

Fever continuing after four to seven days of appropriate antibacterials during expected prolonged neutropenia should trigger renewed source review and a risk-based invasive-fungal assessment.