Febrile neutropenia — definition, MASCC and empirical antibiotics

Definition. Febrile neutropenia = ANC at or below 500 cells per microlitre plus fever 38.3 C or higher once or above 38.0 C maintained over one hour in a patient on chemotherapy / haematological malignancy / transplant immunosuppression.^[6]

Risk. This patient is high risk: profound neutropenia (ANC 100), AML induction, inpatient-level illness, line infection concern. MASCC will be below 21 (symptom burden, inpatient at onset, age may score) — admit for IV therapy, since low MASCC scores carry worse outcomes; not an outpatient oral candidate.^[5][6]

First 60 minutes. Resus assessment; blood cultures before antibiotics — all lumens of the Hickman plus a concurrent peripheral set; lactate, FBC, U&E, LFT, coag, CXR, urine. Do not wait for ANC confirmation if clinical FN. Initial doses of empirical antibacterials within 1 hour of triage with 4+ hours of monitoring. Fluids if hypotensive/lactataemic; early ICU if shock.^[2][8]

Antibiotics. First-line anti-pseudomonal beta-lactam monotherapy — piperacillin-tazobactam IV (supported where resistance profiles do not mandate carbapenems), cefepime IV, ceftazidime IV, or a carbapenem (meropenem or imipenem) IV. Add vancomycin or teicoplanin for suspected catheter-related infection or MRSA cover; stop combination cover at 24 to 72 hours in the responder without a specific microbiologic indication. Source control for line infection with oncology/ID.^[6][8][14]