1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The recommendations in this guideline were developed after discussion of the relevance of the evidence to children, young people and adults with cancer. The recommendations are intended for use in patients of any age. Where age-limited or disease-specific recommendations are made they are clearly indicated as such.

1.1 Information, support and training

1.1.1 Information and support for patients and carers

1.1.1.1 Provide patients having anticancer treatment and their carers with written and oral information, both before starting and throughout their anticancer treatment, on:

  • neutropenic sepsis

  • how and when to contact 24-hour specialist oncology advice

  • how and when to seek emergency care.

1.1.2 Training for healthcare professionals

1.1.2.1 Healthcare professionals and staff who come into contact with patients having anticancer treatment should be provided with training on neutropenic sepsis. The training should be tailored according to the type of contact.

1.2 Reducing the risk of septic complications of anticancer treatment

1.2.1.1 For adult patients (aged 18 years and older) with acute leukaemias, stem cell transplants or solid tumours in whom significant neutropenia (neutrophil count 0.5×109 per litre or lower) is an anticipated consequence of chemotherapy, offer prophylaxis with a fluoroquinolone during the expected period of neutropenia only.

1.2.1.2 Rates of antibiotic resistance and infection patterns should be monitored in treatment facilities where patients are having fluoroquinolones for the prophylaxis of neutropenic sepsis[3].

1.2.1.3 Do not routinely offer G-CSF for the prevention of neutropenic sepsis in adults receiving chemotherapy unless they are receiving G-CSF as an integral part of the chemotherapy regimen or in order to maintain dose intensity.

1.3 When to refer patients in the community for suspected neutropenic sepsis

1.3.1.1 Suspect neutropenic sepsis in patients having anticancer treatment who become unwell.

1.3.1.2 Refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care.

1.4 Managing suspected neutropenic sepsis in secondary and tertiary care

1.4.1 Emergency treatment and assessment

1.4.1.1 Treat suspected neutropenic sepsis as an acute medical emergency and offer empiric antibiotic therapy immediately.

1.4.1.2 Include in the initial clinical assessment of patients with suspected neutropenic sepsis:

  • history and examination

  • full blood count, kidney and liver function tests (including albumin), C-reactive protein, lactate and blood culture.

1.4.2 Further assessment

1.4.2.1 After completing the initial clinical assessment (see recommendation 1.4.1.2) try to identify the underlying cause of the sepsis by carrying out:

  • additional peripheral blood culture in patients with a central venous access device if clinically feasible

  • urinalysis in all children aged under 5 years.

1.4.2.2 Do not perform a chest X-ray unless clinically indicated.

1.4.3 Starting antibiotic therapy

All patients

1.4.3.1 Offer beta lactam monotherapy with piperacillin with tazobactam[4] as initial empiric antibiotic therapy to patients with suspected neutropenic sepsis who need intravenous treatment unless there are patient-specific or local microbiological contraindications.

1.4.3.2 Do not offer an aminoglycoside, either as monotherapy or in dual therapy, for the initial empiric treatment of suspected neutropenic sepsis unless there are patient-specific or local microbiological indications.

Empiric glycopeptide antibiotics in patients with central venous access devices

1.4.3.3 Do not offer empiric glycopeptide antibiotics to patients with suspected neutropenic sepsis who have central venous access devices unless there are patient-specific or local microbiological indications.

1.4.3.4 Do not remove central venous access devices as part of the initial empiric management of suspected neutropenic sepsis.

1.4.4 Confirming a diagnosis of neutropenic sepsis

1.4.4.1 Diagnose neutropenic sepsis in patients having anticancer treatment whose neutrophil count is 0.5×109 per litre or lower and who have either:

  • a temperature higher than 38oC or

  • other signs or symptoms consistent with clinically significant sepsis.

1.5 Managing confirmed neutropenic sepsis

1.5.1 Assessing the patient's risk of septic complications

1.5.1.1 A healthcare professional with competence in managing complications of anticancer treatment should assess the patient's risk of septic complications within 24 hours of presentation to secondary or tertiary care, basing the risk assessment on presentation features and using a validated risk scoring system[5].

1.5.2 Patients at low risk of septic complications

1.5.2.1 Consider outpatient antibiotic therapy for patients with confirmed neutropenic sepsis and a low risk of developing septic complications, taking into account the patient's social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops.

1.5.3 Patients at high risk of septic complications

1.5.3.1 For patients with confirmed neutropenic sepsis and a high risk of developing septic complications, a healthcare professional with competence in managing complications of anticancer treatment should daily:

  • review the patient's clinical status

  • reassess the patient's risk of septic complications, using a validated risk scoring system[5].

1.5.3.2 Do not switch initial empiric antibiotics in patients with unresponsive fever unless there is clinical deterioration or a microbiological indication.

1.5.3.3 Switch from intravenous to oral antibiotic therapy after 48 hours of treatment in patients whose risk of developing septic complications has been reassessed as low by a healthcare professional with competence in managing complications of anticancer treatment using a validated risk scoring system[5].

1.5.3.4 Offer discharge to patients having empiric antibiotic therapy for neutropenic sepsis only after:

  • the patient's risk of developing septic complications has been reassessed as low by a healthcare professional with competence in managing complications of anticancer treatment using a validated risk scoring system[5]and

  • taking into account the patient's social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops.

1.5.4 Duration of empiric antibiotic treatment

1.5.4.1 Continue inpatient empiric antibiotic therapy in all patients who have unresponsive fever unless an alternative cause of fever is likely.

1.5.4.2 Discontinue empiric antibiotic therapy in patients whose neutropenic sepsis has responded to treatment, irrespective of neutrophil count.



[3] For more information see the Department of Health's Updated guidance on the diagnosis and reporting of Clostridium difficile and guidance from the Health Protection Agency and the Department of Health on Clostridium difficile infection: how to deal with the problem.

[4] At the time of publication (September 2012) piperacillin with tazobactam did not have a UK marketing authorisation for use in children aged under 2 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The child's parent or carer should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

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[5] Examples of risk scoring systems include the Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients (Journal of Clinical Oncology 2000; 18: 3038–51) and the modified Alexander rule for children (aged under 18) (European Journal of Cancer 2009; 45: 2843–9).

  • National Institute for Health and Care Excellence (NICE)