Febrile Neutropenia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Confirm + MASCC stratification
   Confirm febrile neutropenia and stratify by MASCC risk? (Fever = a single oral temperature ≥38.3°C or ≥38.0°C sustained ≥1 h; neutropenia = ANC <500/µL (or <1000 expected to fall <500 within 48 h). An oncological emergency. Immediately examine, blood cultures ×2 (including central line), site-specific cultures and imaging — but do not delay antibiotics for these. MASCC ≥21 low-risk, <21 high-risk.)
   • High-risk (MASCC <21 / unstable) → High-risk → IV monotherapy within 1 h
   • Low-risk (MASCC ≥21, stable, can follow up) → Low-risk → oral outpatient possible
2. [End] High-risk → IV monotherapy within 1 h
   Empiric IV anti-pseudomonal beta-lactam monotherapy within 1 h — cefepime, piperacillin-tazobactam or a carbapenem (meropenem). Vancomycin is not first-line; add it only for catheter-related infection, skin/soft tissue, pneumonia, hemodynamic instability, known MRSA colonization or severe mucositis. If unstable/suspected resistance/pneumonia, add combination cover (an aminoglycoside or dual cover). Admit, monitor, reassess daily; for persistent fever at 3–5 days investigate and start empiric antifungals.
3. [End] Low-risk → oral outpatient possible
   Low-risk (MASCC ≥21, clinically stable, adherent and can follow up): an oral regimen (ciprofloxacin + amoxicillin-clavulanate) with outpatient management/short observation and close follow-up; avoid a fluoroquinolone if one was used for prophylaxis. Still send blood cultures first and do not delay dosing; escalate to a high-risk IV regimen and admit if worsening.

Source guidelines & references

• IDSA Clinical practice guideline on antimicrobial use in neutropenic cancer patients
• MASCC risk-index score

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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