Neutropenic Sepsis

Neutropenic sepsis is a medical emergency in patients with neutrophils <1.0 × 10⁹/L (severe <0.5) with fever ≥38°C or clinical suspicion of sepsis. Antibiotics must be given within 60 minutes of recognition. Mortality is 2–21% — delays are fatal…

UKONS Neutropenic Sepsis Pathway

The pathway

1 · Recognise

Any patient on systemic anti-cancer treatment (SACT) with fever ≥38°C or feeling unwell. Neutropenia confirmed by FBC. Fever may be absent in profound neutropenia — any deterioration counts.

2 · Sepsis 6 adapted

O₂ if needed
Blood cultures (peripheral x2 + from each lumen of central line)
IV antibiotics ASAP
FBC urgently — if neutrophils <1.0, treat as neutropenic sepsis regardless of source

3 · Broad-spectrum antibiotics within 60 min

Piperacillin-tazobactam (Tazocin) 4.5g IV Q8h first-line
Or meropenem 1g IV Q8h if Tazocin-resistant organisms likely
Do NOT add a glycopeptide just because there is a central line (NICE CG151) — only for a patient-specific or local microbiological indication
Do NOT remove the line as part of initial empiric management

4 · Identify source & risk stratify

MASCC score ≥21 = low risk
Blood cultures
CXR
urine dip
line inspection
dental screen
CT chest/abdomen if source unclear or high-risk

5 · GCSF (Granulocyte colony-stimulating factor)

Filgrastim SC prescribed by oncology team. Consider in life-threatening neutropenic sepsis or prolonged neutropenia. Do NOT use as routine first-line — requires oncology input.

6 · Antimicrobial review at 48–72h

Reassess with blood culture results. Narrow antibiotics if possible. If febrile at 72–96h despite Abx: add antifungal (fluconazole/caspofungin). Contact oncology + haematology for all cases.

Drugs

Drug	Dose	Route	Notes
Piperacillin-tazobactam	4.5g Q8h	IV	First-line in neutropenic sepsis. Give within 60 minutes.
Meropenem	1g Q8h	IV	Broad-spectrum. Use if ESBL/resistant organisms suspected.
Vancomycin	1g Q12h (levels-guided)	IV	Not empirically for a central line alone (CG151 1.4.3.3). Add only on a patient-specific or local microbiological indication. Levels 48h after starting.
Caspofungin	70mg stat, then 50mg OD	IV	If still febrile at 72–96h on Abx. Empirical antifungal.

When to escalate

Haemodynamic instability — ITU, vasopressors (noradrenaline),MASCC score <21 (high-risk) — inpatient admission mandatory,Still febrile at 72h despite antibiotics — consider fungal, resistant organisms, ITU,Suspected typhlitis (RIF pain, diarrhoea) — CT abdomen + surgical review

Reference: UKONS Neutropenic Sepsis Guidelines 2023 / NICE NG151

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