Synopsis
Recognise infection despite muted signs, treat febrile neutropenia as an emergency, tailor investigations and antimicrobials to the immune defect, and escalate deterioration without waiting for microbiological proof.
- Immunocompromise is not one diagnosis: define whether neutrophils, T cells, B cells or antibody, complement, splenic function or physical barriers are impaired.
- Ask for the named condition, current and recent chemotherapy, transplant, biologic and steroid doses, prophylaxis, central access, colonisation, previous organisms and the written emergency plan.
- After anticancer treatment, fever above 38°C with neutrophils 0.5 × 10^9/L or lower meets the NICE neutropenic-sepsis definition; clinical sepsis can meet it without documented fever.
- Treat suspected neutropenic sepsis as an acute medical emergency and give empirical antibiotics immediately; do not wait for the neutrophil count, C-reactive protein, imaging or culture result.
- Initial tests are FBC with differential, renal and liver profile including albumin, CRP, lactate and blood culture; take cultures from each relevant line lumen and a peripheral sample when possible.
- For children under 5, perform urinalysis as part of initial assessment. Do not request a routine chest radiograph unless respiratory signs or another clinical indication exists.
- NICE first-line empirical treatment is intravenous piperacillin with tazobactam monotherapy unless allergy, previous resistance or local microbiology requires another regimen.
- Do not routinely add an aminoglycoside, and do not add a glycopeptide solely because a central line is present. Additions require physiology, a suspected focus, colonisation or microbiological evidence.
- Do not remove a central venous catheter during initial empirical management unless there is a specific clinical or microbiological indication.
- Reassess repeatedly. Persistent fever alone in a stable child is not a reason to change broad-spectrum antibiotics; deterioration or microbiological evidence is.
- Use a validated paediatric risk assessment within 24 hours and repeat it daily. Outpatient oral treatment is reserved for specialist-confirmed low risk with robust access and follow-up.
- Prolonged neutropenia and persistent or recurrent fever require invasive-fungal assessment and specialist antifungal decisions; ordinary bacterial, viral and noninfectious causes remain possible.
- Neutropenia may prevent pus and inflammation, steroids may suppress fever, and antibody deficiency may reduce serological responses; normal-looking findings do not offer ordinary reassurance.
- Manage non-neutropenic immunocompromised fever through the immune defect and syndrome: transplant, primary immunodeficiency, asplenia and complement blockade have different likely pathogens and thresholds.
Key red flags
Any temperature above the child's oncology threshold, or feeling acutely unwell without fever, requires immediate contact with the designated treatment centre and must not wait for a routine appointment.
Hypotension, prolonged capillary refill, altered mental state, rising lactate, oliguria, increased oxygen requirement or mottling indicates sepsis with organ dysfunction and needs critical-care escalation.
Rigors during central-line use, tunnel erythema, discharge, line pain or haemodynamic change raises catheter-associated bloodstream infection, but a normal-looking line does not exclude it.
Vesicular rash, eye involvement, hepatitis, pneumonitis, encephalopathy or a significant varicella exposure can represent disseminated herpesvirus infection and needs immediate isolation and specialist antiviral advice.
New focal neurology, severe headache, meningism, seizure or reduced consciousness requires emergency CNS-infection assessment while considering thrombocytopenia and raised intracranial pressure before lumbar puncture.
Persistent fever with prolonged neutropenia, pleuritic pain, hypoxia, sinus symptoms, skin nodules or new lung lesions raises invasive fungal disease.
Investigation priorities
Identify bacteraemia and guide narrowing, resistance management and catheter decisions.
Measure absolute neutrophil count, anaemia and thrombocytopenia and establish treatment safety.
Management branches
A child after anticancer treatment has fever above the agreed threshold or signs consistent with clinically significant sepsis.
- Activate the oncology or specialist emergency pathway, assess ABCDE and glucose, obtain current weight and involve senior paediatrics and the responsible treatment centre.
- Take central and peripheral cultures where possible plus FBC, renal and liver profile, albumin, CRP and lactate without delaying therapy.
- Give intravenous piperacillin with tazobactam immediately unless allergy, previous resistance or local microbiology dictates a different empirical regimen, and escalate organ support early.
The child is clinically stable and a validated paediatric assessment indicates low risk after initial management.
- Complete the validated risk assessment within 24 hours and repeat it daily, confirming culture status, focus, neutrophil trajectory and response.
- Use oral or outpatient treatment only when the specialist protocol permits and transport, telephone, adherence, home observation and rapid return are reliable.
- Provide exact return thresholds, named contact, next review and ownership of pending cultures or fungal tests before discharge or antibiotic cessation.