Febrile Neutropenia 🌡️
Emergency management of febrile neutropenia: assessment, immediate actions, antibiotic protocols, and monitoring for NCHDs.
🚨 Definition & Recognition
- Fever ≥38°C (or ≥38.3°C single reading) + Neutrophil count <0.5 x 10⁹/L (or <1.0 x 10⁹/L with expected decline)
- OR temperature ≥38°C for >1 hour + Neutrophil count <0.5 x 10⁹/L
- Medical emergency - mortality 5-10% if untreated
- Most common in patients receiving chemotherapy, especially for hematological malignancies
- Can occur 7-14 days after chemotherapy (nadir period)
⚡ Immediate Actions (First 30 minutes)
- ABC assessment and vital signs
- Blood cultures x2 (peripheral + central line if present)
- FBC, U&E, LFTs, CRP, lactate
- Chest X-ray if respiratory symptoms
- Urine culture and MSU
- Start broad-spectrum antibiotics within 1 hour
- Consider G-CSF if severe neutropenia
- Notify oncology/haematology team immediately
🔍 Assessment & Risk Stratification
- High Risk: Hypotension, dehydration, severe comorbidity, organ dysfunction
- Low Risk: No organ dysfunction, good social support, stable vitals
- Consider source of infection: line-related, respiratory, GI, skin/soft tissue
- Assess for signs of sepsis: altered GCS, hypotension, tachypnea, lactate >2
📊 Monitoring & Response
- Vital signs every 4 hours (more frequent if unstable)
- FBC daily until neutrophil recovery
- Blood cultures daily if fever persists
- Review antibiotics at 48-72 hours based on cultures and clinical response
- Consider imaging if fever persists >72 hours (CT chest/abdomen)
- Monitor for signs of sepsis or organ dysfunction
🩸 Supportive Care
- G-CSF (filgrastim) 5mcg/kg SC daily until neutrophil recovery
- Blood transfusion if Hb <80g/L and symptomatic
- Platelet transfusion if platelets <10 x 10⁹/L (or <20 x 10⁹/L with bleeding)
- IV fluids if dehydrated or hypotensive
- Paracetamol for fever (avoid NSAIDs due to bleeding risk)
- Isolation precautions if neutropenic
⚠️ Red Flags - Escalate Immediately
- Hypotension (SBP <90mmHg) or signs of shock
- Altered consciousness or confusion
- Severe respiratory distress or hypoxia
- Severe abdominal pain or peritonism
- Rash suggesting infection (meningococcal, viral)
- Signs of line infection (redness, swelling, purulent discharge)
- No response to antibiotics after 48-72 hours
🏥 Discharge Criteria (Low Risk Only)
- Afebrile for 24 hours
- Neutrophil count >0.5 x 10⁹/L and rising
- No signs of infection or organ dysfunction
- Able to take oral antibiotics
- Good social support and reliable follow-up
- Oncology team approval