Febrile neutropenia — Rapid | Doctor’s Passport

Synopsis

Recognise fever or sepsis in an immunocompromised child even when inflammatory signs are muted, deliver cultures and broad-spectrum IV antibiotic in the correct time-critical order, identify source and organ dysfunction, and use paediatric oncology risk stratification safely.

Treat suspected neutropenic sepsis as an acute medical emergency and give empirical antibiotic immediately; paediatric oncology services target the first IV dose within 60 minutes of arrival.
CCLG defines paediatric febrile neutropenia as ANC below 0.5 × 10^9/L with temperature 38°C or above once, or clinically significant sepsis features; follow the child's treatment card and local threshold.
Parent-reported fever counts, and hypothermia or an unwell afebrile child can represent sepsis; do not wait for a repeat temperature or the neutrophil result when risk is clear.
First-line assessment is ABCDE, current treatment and nadir timing, central-line and prior microbiology review, full examination without rectal instrumentation, and paediatric early-warning score.
First-line bloods are FBC, kidney and liver function including albumin, CRP, lactate and blood culture; culture every central-line lumen and obtain peripheral culture when feasible without delaying antibiotics.
First-line empirical IV therapy for a child needing IV treatment is piperacillin–tazobactam monotherapy unless allergy, resistance history, recent treatment or local microbiology contraindicates it.
A commonly used UK paediatric oncology regimen is piperacillin–tazobactam 90 mg/kg IV every 6 hours, maximum 4.5 g per dose, with renal adjustment.
Do not add an aminoglycoside routinely; add targeted broader cover for haemodynamic compromise, resistant colonisation, line or skin infection, or microbiological indication under local specialist guidance.
Do not perform rectal temperature, examination, suppository or enema; mucosal trauma can cause bacteraemia and bleeding.
Do not obtain routine chest radiography without clinical indication; examine and image a suspected focus while the broad-spectrum antibiotic is already running.
Only a validated paediatric oncology risk tool after initial IV therapy can support early oral switch or discharge; apparent wellness at triage is not enough.

Key red flags

Hypotension, prolonged capillary refill, altered consciousness, rising lactate, oliguria or respiratory distress indicates septic shock and requires critical-care escalation.

Severe abdominal pain, distension, diarrhoea or right-sided tenderness may indicate neutropenic enterocolitis; avoid deep palpation and involve oncology, surgery and imaging teams.

Pain, erythema, discharge or tunnel tenderness around a central line, or rigors during line access, suggests catheter-related infection.

Focal skin pain, perianal symptoms, oral mucositis or new respiratory features can be the only local clue because pus and inflammatory signs are attenuated.

A low temperature below 36°C, parent-reported fever before arrival or an unwell afebrile child remains sepsis-positive in this population.

Previous ESBL, MRSA, Pseudomonas or other resistant isolate, severe beta-lactam allergy, recent high-dose methotrexate or renal impairment changes the empirical antibiotic plan.

Investigation priorities

First-line FBC with differentialFirst stepFirst line

Measure absolute neutrophil count and identify concurrent anaemia or thrombocytopenia affecting procedures and support.

First-line blood culturesFirst line

Identify bloodstream pathogen and susceptibility from every central lumen and peripheral blood when feasible.

Management branches

First 60 minutesCulture and treat in parallel

An at-risk child has fever, hypothermia or clinically significant sepsis features.

Start ABCDE, observations, early-warning scoring and immediate oncology notification.
Draw cultures from each line lumen and peripheral blood plus initial laboratory tests without delay.
Give first-line IV piperacillin–tazobactam or the pre-agreed alternative within 60 minutes.
Document allergy, prior resistance, renal function and exact door-to-antibiotic time.

Stable after initial therapyRisk-stratify formally

The child remains clinically stable after first-dose IV treatment and initial assessment.

Review cultures, ANC trajectory, diagnosis, treatment phase, focus, comorbidity and family logistics.
Apply the principal treatment centre's validated paediatric low-risk tool.
Use protocol-defined continuation, oral switch or discharge rather than an ad hoc decision.
Provide direct-access and exact temperature and illness return criteria.

Key medicines

Piperacillin with tazobactamGive 90 mg/kg per dose IV every 6 hours, maximum 4.5 g per dose, as first-line monotherapy within 60 minutes for a child aged over 1 month under the local paediatric oncology protocol.Check immediate and delayed beta-lactam allergy, previous resistant organisms and recent high-dose methotrexate; adjust at reduced GFR, monitor renal, hepatic and haematological effects, and use the local antimicrobial policy because ecology and infusion method vary.

Gentamicin for selected haemodynamic compromiseWhen the local paediatric oncology and microbiology protocol indicates aminoglycoside cover, give 5 mg/kg IV as the initial once-daily dose and check the level before any subsequent dose, awaiting the result as required by the protocol.Avoid unnecessary use, obtain current weight and renal function, account for cisplatin, renal tumour or other nephrotoxic exposure, monitor drug levels and hearing or renal toxicity, and seek pharmacy or microbiology advice in impairment.

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