Paeds · infectious-diseases
Infections in immunocompromised children
Also known as Febrile neutropenia · Opportunistic infection in children · Infection in the cancer or transplant child · Immunocompromised host infection · Overwhelming post-splenectomy infection
A fellowship-depth approach to infections in immunocompromised children: classify the immune-defect type and its signature organisms, understand why fever and signs are blunted, run the immunocompromised-fever threat gate first, deliver empiric therapy within 60 minutes, and manage organism-specific syndromes from fever-and-neutropenia through Pneumocystis, invasive fungal disease, CMV, adenovirus, central-line sepsis and overwhelming post-splenectomy infection.
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Target exams
Red flags
- Any fever in a child with neutropenia, transplant, chemotherapy, primary immunodeficiency, or asplenia — regardless of appearance
- Hypothermia or a normal temperature in a child who should be febrile — sepsis can present without fever in these hosts
- Isolated tachypnoea, subtle confusion, or a fall in baseline interaction as the only sepsis sign
- Pain or erythema at a central venous catheter exit site or along the tunnel
- Hypoxaemia disproportionate to chest auscultation — think Pneumocystis pneumonia
- Persistent fever beyond four days of broad-spectrum therapy — escalate the antifungal search
- A well-looking asplenic child with fever — overwhelming post-splenectomy infection can kill within hours
- New pulmonary nodules, sinus pain or skin lesions on imaging in a persistently febrile child — invasive fungal disease
Life stages
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Clinical exam formats
Board mappings
- General and Community Paediatrics
- Acute and emergency assessment
- Infectious Diseases
- Immunology and allergy
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Oncology and immunology shared-care and infection risk
- Infectious Diseases 10–12
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 9. Infection, Immunology and Allergy
- 11. Oncology / Safe and effective care in complex chronic conditions
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — D4 Infectious Diseases (7%)
- General Pediatrics Content Outline — D5 Oncology (6%)
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Medical Knowledge 3: Infectious Diseases
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Foundations EPA #8 — Communicating assessment findings and management plans to patients and/or families
- Pediatrics: Infectious Diseases (5–10%)
A registrar hands you a child on chemotherapy who has spiked a fever at home. The child looks well, is playing on the bed, and the temperature is only 38.1 °C. The trap is to be reassured. The whole principle of this topic is that the missing immune compartment — whether neutrophils, T-cells, antibody, or spleen — removes the early-warning system that tells you a normal host is sick. Height of fever correlates poorly with serious bacterial infection even in immunocompetent children, and the relationship is weaker still when the inflammatory response itself is disabled. [4]
This page owns the approach to infections in immunocompromised children. It sits beside the sister pages on paediatric sepsis, fever by age and immune status, fungal infections, EBV and CMV, and antimicrobial stewardship. Those pages take the organism-specific depth; this page builds the unifying framework a fellowship candidate must defend at viva. [1] [14]
Well-looking is not safe · Every lumen plus a peripheral culture · Anti-pseudomonal within the hour · Know the defect — it predicts the organism · Height of fever is a distraction · Opportunistic organisms when T-cells fall · Spleen absent means encapsulated threat · Threat gate overrides appearance, always. [1] [4]
Overview & Definition
An immunocompromised child is one whose immune system cannot mount the response a normal host would mount to the same organism. The compromise may be inherited, as in primary immunodeficiency; acquired, as in chemotherapy-induced neutropenia or HIV; iatrogenic, as in post-transplant immunosuppression; or structural, as in asplenia or the presence of an indwelling central venous catheter. What unites these children is a shared clinical problem: the usual signs of infection — fever, localising pain, pus, an inflammatory wall — are blunted or absent, so the window between treatable infection and overwhelming sepsis narrows. [1]
Fever in the immunocompromised host is defined operationally, not arbitrarily. In the febrile-neutropenia pathway, fever is a single oral or tympanic reading at or above 38.3 °C, or two readings at or above 38.0 °C taken at least an hour apart. Neutropenia — an absolute neutrophil count below 0.5 × 10⁹/L, or below 1.0 × 10⁹/L with an expected fall — is the qualifier that converts a febrile child into a febrile-neutropenic emergency. The definition matters because the threshold triggers an entire pathway that does not wait for proof of infection. [1]
References14ShowHide
- [1]Lehrnbecher T Guideline for the Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients: 2023 Update. Journal of clinical oncology, 2023.PMID 36689694
- [2]Schlapbach LJ International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024.PMID 38245889
- [3]Weiss SL Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatric critical care medicine, 2026.PMID 41869844
- [4]De S Lack of Accuracy of Body Temperature for Detecting Serious Bacterial Infection in Febrile Episodes. The Pediatric infectious disease journal, 2015.PMID 26065864
- [5]Biondi EA Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis. JAMA network open, 2019.PMID 30901044
- [6]Groll AH 8th European Conference on Infections in Leukaemia: 2020 guidelines for the diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or post-haematopoietic cell transplantation. The Lancet. Oncology, 2021.PMID 33811813
- [7]Cornely OA Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM. The Lancet. Infectious diseases, 2025.PMID 39956121
- [8]Maertens J ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. The Journal of antimicrobial chemotherapy, 2016.PMID 27550992
- [9]Kotton CN The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation, 2018.PMID 29596116
- [10]Hsu AJ Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrobial agents and chemotherapy, 2022.PMID 35766509
- [11]Bavare AC Central Line-Associated Bloodstream Infections in Pediatrics: A Review. Pediatrics in review, 2025.PMID 40875258
- [12]Lee GM Preventing infections in children and adults with asplenia. Hematology. American Society of Hematology. Education Program, 2020.PMID 33275684
- [13]Cesaro S Adenovirus infection in allogeneic hematopoietic cell transplantation. Transplant infectious disease, 2023.PMID 37846850
- [14]Srinivasan A Timeline, epidemiology, and risk factors for bacterial, fungal, and viral infections in children and adolescents after allogeneic hematopoietic stem cell transplantation. Biology of blood and marrow transplantation, 2013.PMID 22922523