Initial Management of Febrile Neutropenia in adults

Initial Management of Febrile Neutropenia in adults


Febrile neutropenia is a medical emergency; complete assessment and initiate treatment within one hour

If the patient is being actively treated on a research protocol with an investigational oncologic agent, please contact the on-call oncologist within 24 hours of admission

  • A single oral temperature ≥38.3°C or ≥38°C lasting at least 1 hour


  • An absolute neutrophil count <0.5 x 10⁹ cells/L or <1 x 10⁹ cells/L on a downward trend

“Afebrile” febrile neutropenia may occur in elderly patients, or in patients taking systemic corticosteroids, and can present in the form of hypothermia or unexplained clinical deterioration

Initial Evaluation and Management

Initial physical examination should include, but not be limited to: sinuses, oral mucosa, eyes, skin and IV access sites, perianal region (without digital rectal exam), feet

Attention: Herpetic stomatitis can resemble toxic mucositis. If in doubt, order a herpes PCR assay and consider adding an empiric antiherpetic agent (e.g. acyclovir)

  • CBC with differential, liver function tests, electrolytes, creatinine, urea, lipase daily x 3 days, then reassess
  • Blood cultures x 2 sets simultaneously (before administering antibiotics). DO NOT withhold antibiotics for more than one hour. If central IV catheter present, obtain 1 set via peripheral site and 1 set via each lumen of the central catheter
  • Urinalysis and culture

May also consider:

  • Sputum culture
  • Stool culture
  • C. difficile assay
  • Influenza assay
  • Chest radiography (PA + LAT)

+/- other imaging according to clinical judgment

  • Vital signs QID (or more frequently according to the patient's condition)
  • Protective (neutropenic) isolation +/- other measures according to isolated/suspected organisms (e.g. influenza, C. difficile, etc.)

Oncology patients are at high risk for thromboembolism. Please refer to local thromboprophylaxis pre-printed orders to evaluate/prescribe appropriate thromboprophylaxis, unless contraindicated.

Additional Information

Content derived from the Vitalité regional clinical order set: Initial Management of Febrile Neutropenia in Adults.