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Clinical reference
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EmergencyAwaiting clinical review · Pending oncology pharmacist sign-off

Febrile neutropenia

Time-critical. Empiric broad-spectrum antibiotics within 60 minutes of the first recorded fever.

Fever threshold
≥38.0 °C once, or ≥37.5 °C twice 1 h apart
ANC threshold
<0.5 ×10⁹/L (or <1.0 and falling)
Door-to-antibiotic
≤60 min

First 60 minutes

  • Triage as an emergency on arrival — do not wait for the blood count to return.
  • Full observations including perfusion and capillary refill; weight for dosing.
  • Blood cultures from every central line lumen, plus peripheral if a line is absent.
  • FBC with differential, CRP, U&E, LFTs, lactate, coagulation if unwell.
  • Give the first empiric antibiotic dose immediately after cultures are drawn.

Escalate

  • Hypotension, prolonged capillary refill, altered consciousness or rising lactate — escalate to the sepsis pathway and involve PICU now.
  • Never delay antibiotics for imaging, line access difficulty, or a pending count.

Empiric cover (verify against local formulary)

  • Monotherapy with an antipseudomonal beta-lactam is the usual first line (e.g. piperacillin-tazobactam or meropenem where local resistance dictates).
  • Add a glycopeptide for suspected line infection, skin/soft-tissue focus, MRSA colonisation or haemodynamic instability.
  • Add an aminoglycoside per local policy in septic shock or known resistant Gram-negative carriage.
  • Document the indication for any added agent so it can be de-escalated at 48 h.

First 48 hours

  • Reassess at least twice daily; repeat cultures if fever persists or the child deteriorates.
  • Review at 48 h: de-escalate if cultures are negative and the child is stable and afebrile.
  • Consider fungal work-up (CT chest, galactomannan) if fever persists beyond 96 h of broad-spectrum cover.
  • Low-risk patients may step down to oral therapy only under a defined local pathway.

Sources and local override

  • Institutional febrile neutropenia pathway — Local pathway supersedes this summary in all cases.
  • Paediatric sepsis six — Escalation triggers and time targets.

Next review due 2027-02-01.