Febrile neutropenia — MASCC, regimens and antifungal escalation viva

Low-risk patient. MASCC 21 or more (positive predictive value 91 percent, specificity 68 percent, sensitivity 71 percent), short expected neutropenia, stable vitals, reliable follow-up → candidate for oral outpatient therapy with an oral fluoroquinolone plus amoxicillin-clavulanate after cultures and 4+ hours of monitoring, with re-evaluation for admission if not defervescing after 2 to 3 days. Oral ciprofloxacin plus amoxicillin-clavulanate succeeded in 71 percent of low-risk episodes.^[2][5][12]

High-risk IV standard. Anti-pseudomonal monotherapy: pip-tazo IV, cefepime, ceftazidime, or a carbapenem. Initial doses within 1 hour of triage.^[2][6]

Add-ons. Vancomycin or teicoplanin only where MRSA cover is indicated. Empirical antifungal therapy — caspofungin on high-quality evidence — for persistent fever despite broad-spectrum cover in the high-risk patient.^[6][9]

Pitfalls. Waiting for ANC; discharging high-risk without oncology; missing the 2-to-3-day re-evaluation window in the low-risk outpatient.^[2]