Febrile neutropenia and infection in oncology

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Target exams

Red flags

• A single temperature of 38.5 degrees Celsius or higher, or 38.0 degrees Celsius or higher sustained over one hour, in a child with an absolute neutrophil count under 0.5 times ten to the ninth per litre is presumed bacteraemic and needs blood cultures plus empiric intravenous anti-pseudomonal beta-lactam within the first hour; the signs of sepsis are blunted when there are no neutrophils, so a well appearance must not reassure
• Any clinical instability in a febrile neutropenic child, including hypotension, prolonged capillary refill, mottling, hypoxia, oliguria, altered mental state or rigors, makes the child high-risk and demands inpatient intravenous monotherapy, early shock resuscitation, and escalation to intensive care
• Never perform a rectal examination, take a rectal temperature, insert a rectal suppository, or give a non-steroidal anti-inflammatory in the neutropenic child; these seed infection and mask the only reliable vital sign
• Persistent fever beyond 96 hours in a high-risk child signals invasive fungal infection or an occult focus, and prompts re-culture, imaging, and the addition of an empiric or pre-emptively targeted antifungal agent such as liposomal amphotericin B, caspofungin or voriconazole
• A central-line tunnel infection, a port-pocket abscess, or a catheter-related bloodstream infection that persists beyond 72 hours of appropriate antibiotics requires line removal, as do bacteraemias with Staphylococcus aureus, Pseudomonas aeruginosa, Candida, Bacillus, atypical mycobacteria or vancomycin-resistant enterococci
• Routine empiric vancomycin is not recommended; add it only for suspected line infection, mucositis, a serious soft-tissue or pulmonary focus, haemodynamic instability, severe sepsis, or known colonisation with methicillin-resistant Staphylococcus aureus

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines febrile neutropenia as fever of 38.5 degrees Celsius or 38.0 degrees Celsius over an hour with an absolute neutrophil count under 0.5, and recognises it as a same-hour medical emergency requiring empiric intravenous anti-pseudomonal monotherapy within the first hour
• Lists the standard empiric monotherapy options of ceftazidime, piperacillin-tazobactam, cefepime and meropenem, and the indications for adding vancomycin
• States that blood cultures must be drawn from every central line lumen and peripherally before but never delaying the first antibiotic dose
• Applies the high-risk and low-risk risk stratification of the International Pediatric Fever and Neutropenia Guideline and explains how it sets disposition and duration
• Explains the mechanism of blunted inflammation in neutropenia and the implication that fever may be the only sign of bacteraemia
• Justifies the role of granulocyte colony-stimulating factor as prophylaxis in high-risk regimens and as a considered adjunct, not a routine treatment of established febrile neutropenia
• The first-hour management bundle of the febrile neutropenic child, including empiric monotherapy and the indications for vancomycin
• Risk stratification and the decision between continued inpatient intravenous therapy and oral step-down or outpatient care
• The recognition of clinical instability and early septic shock in a child in whom the signs of sepsis are blunted
• Bedside assessment of the febrile neutropenic child, including the active search for a source while protecting the child from rectal instrumentation
• Communication with the family of an oncology child around a febrile-neutropenia admission, the safety-net, and the outpatient option for the low-risk child
• Coordination of multidisciplinary care across oncology, infectious diseases, the line service and pharmacy, including antimicrobial stewardship
• Level 1: Recognises febrile neutropenia as an emergency requiring empiric antibiotics within the first hour
• Level 2: Applies the risk stratification, the indications for vancomycin, and the approach to persistent fever and empiric antifungal therapy
• Level 3: Leads the longitudinal supportive-care strategy of prophylaxis, line care, oral hygiene, and the de-escalation and stewardship decisions
• Definition of fever in neutropenia and the absolute-neutrophil-count threshold
• High-risk versus low-risk risk stratification criteria
• Empiric antibiotic choice and the indications for adding vancomycin, and the approach to persistent fever
• Assessment and first-hour management of a febrile neutropenic child on the acute paediatric oncology ward
• Communication of the diagnosis, the plan, and the safety-net to the family
• Identification and management of a central-line infection and the decision to remove the line
• Recognition of febrile neutropenia and the first-hour empiric anti-pseudomonal monotherapy with blood cultures
• Application of the International Pediatric Fever and Neutropenia Guideline risk stratification
• Management of persistent fever and the indications for empiric antifungal therapy and line removal
• Door-to-antibiotic within the first hour for the febrile neutropenic child and the avoidance of rectal instrumentation
• Risk stratification and the de-escalation and stewardship pathway
• Recognition of the high-risk subtypes including the stem-cell transplant recipient and the child with relapsed leukaemia
• Diagnosis and first-hour management of febrile neutropenia in the Canadian paediatric oncology population
• Application of the risk stratification and the oral step-down or outpatient option for selected low-risk children
• Supportive-care strategy of prophylaxis, oral hygiene, line care and family-centred safety-netting