Last reviewed:October 2019
Last updated:October  2018



History and exam

Key diagnostic factors

  • recent chemotherapy
  • fever
  • tachycardia
  • hypotension

Other diagnostic factors

  • age >65 years
  • prior episodes of neutropenia following chemotherapy
  • Eastern Cooperative Oncology Group performance status (ECOG PS) ≥1
  • hematologic malignancies
  • prior antibiotic regimens
  • albumin <3.5 g/dL
  • pretreatment hemoglobin <12 g/dL
  • low first-cycle nadir blood cell counts (absolute neutrophil count [ANC] <500 PMN/microliter)
  • abnormal breath sounds or cough
  • shortness of breath
  • abdominal pain
  • nausea or vomiting
  • diarrhea
  • dysuria
  • skin erythema, warmth, tenderness
  • mucositis or oral ulcers
  • infection, inflammation, or ulceration of genital and anal area
  • infected indwelling lines
  • concurrent radiation therapy
  • exposures to infections
  • sinus tenderness

Risk factors

  • age >65 years
  • albumin <3.5 g/dL
  • pre-existing organ dysfunction (cardiac, renal, liver disease)
  • pretreatment hemoglobin <12 g/dL
  • full-dose intensity chemotherapy
  • low first-cycle nadir blood cell counts (absolute neutrophil count (ANC) <500 PMN/microliter)
  • hematologic malignancies
  • concurrent radiation therapy
  • female gender
  • Eastern Cooperative Oncology Group performance status (ECOG PS) >1
  • advanced-stage disease
  • prior chemotherapy

Diagnostic investigations

1st investigations to order

  • CBC and differential
  • BUN and creatinine
  • LFTs
  • blood cultures for bacteria: peripheral and central lines
  • CXR
Full details

Investigations to consider

  • stool culture
  • urine culture
  • lumbar puncture
  • fungal cultures and serologies (beta-glucan and galactomannan)
  • viral cultures
  • culture for acid-fast bacilli (AFB)
  • echocardiogram
  • CT scans of the chest, abdomen, and pelvis
Full details

Treatment algorithm


Instructor in Medicine

Dana Farber Cancer Institute




CJ declares that she has no competing interests.

Dr Caron Jacobson would like to gratefully acknowledge Dr Joseph Antin, a previous contributor to this monograph. JA declares that he has no competing interests.

Peer reviewersVIEW ALL

Price Eminent Scholar and Professor of Medicine


Bone Marrow Transplant Program

Division of Hematology/Oncology

University of Florida College of Medicine




JW has been reimbursed by Pfizer, Merck, Astellas, and Enzon for speaking fees, fees for educational programs, and consulting.


Alfa Institute of Biomedical Sciences





MF declares that he has no competing interests.

Senior Lecturer in Haematology

Honorary Consultant in Medical Oncology

St George's University of London




RP has received speaker fees and been reimbursed by Roche, Amgen, Chigai, and Bayer for attending several conferences. RP is a co-author of the EORTC guidelines referenced in this monograph.

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