Febrile neutropenia and infection in oncology: Viva

Branch 1: Recognition and the first-hour bundle

The candidate must open by naming the syndrome in one sentence: 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 febrile neutropenia, and this child meets both thresholds (Lehrnbecher et al., J Clin Oncol 2017, PMID 28459614). The first action is to treat him as presumed bacteraemic, because the signs of sepsis are blunted when the neutrophil count is near zero and fever is often the only reliable signal. The candidate should state the absolute-neutrophil-count formula aloud: the white cell count multiplied by the percentage of segmented neutrophils plus bands, divided by one hundred. ^[2]

The examiner will press on the urgency. The candidate should cite the systematic review of Koenig and colleagues, which found that a shorter time to antibiotics is associated with better clinical outcomes in patients with fever and neutropenia during chemotherapy for cancer, and should name the door-to-antibiotic target of under sixty minutes (Koenig et al., Support Care Cancer 2020, PMID 31264188). The UK audit of Morgan and Phillips documented that this first hour is still missed in a substantial fraction of children, so the candidate should stress that the blood cultures are drawn from every central-line lumen and peripherally before the dose, but they must never delay it. An avoidable delay here is an avoidable harm. ^[7]

The examiner will ask which empiric agent to give. The candidate should name an anti-pseudomonal beta-lactam as monotherapy, ceftazidime, piperacillin-tazobactam, cefepime, or meropenem, weight-dosed by the oncology protocol, because these cover Pseudomonas aeruginosa, which carries the highest mortality, alongside the common Gram-positive and Gram-negative organisms (Freifeld et al., Clin Infect Dis 2011, PMID 21258094). The candidate should then give the indications for adding vancomycin: suspected line infection, a serious soft-tissue or pulmonary focus, mucositis, haemodynamic instability, severe sepsis, or known colonisation with methicillin-resistant Staphylococcus aureus. Routine empiric vancomycin is not recommended because it adds nephrotoxicity without a mortality benefit. ^[1]