Febrile neutropenia

Last reviewed: 29 Oct 2022
Last updated: 27 Nov 2019



History and exam

Key diagnostic factors

  • recent chemotherapy
  • fever
  • tachycardia
  • hypotension
More key diagnostic factors

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 absolute neutrophil count (<500 cells/microliter)
  • abnormal breath sounds or cough
  • shortness of breath
  • abdominal pain
  • nausea or vomiting
  • diarrhea
  • dysuria and pyuria
  • skin erythema, warmth, tenderness
  • mucositis or oral ulcers
  • infection, inflammation, or ulceration of genital and anal area
  • infected indwelling catheters
  • concurrent radiation therapy
  • exposures to infections
  • sinus tenderness
Other diagnostic factors

Risk factors

  • age >65 years
  • albumin <3.5 g/dL
  • pre-existing organ dysfunction (heart, liver, kidney disease)
  • pretreatment hemoglobin <12 g/dL
  • full-dose intensity chemotherapy
  • low first-cycle nadir absolute neutrophil count (<500 cells/microliter)
  • hematologic malignancies
  • concurrent radiation therapy
  • prior episodes of neutropenia following chemotherapy
  • female sex
  • Eastern Cooperative Oncology Group performance status (ECOG PS) >1
  • advanced-stage disease
  • prior chemotherapy
  • corticosteroids
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC and differential
  • BUN and creatinine
  • liver function tests (LFTs)
  • blood cultures for bacteria: peripheral and central venous catheters
  • chest x-ray
More 1st investigations to order

Investigations to consider

  • stool culture
  • urine culture
  • lumbar puncture
  • fungal cultures and serologies (beta-glucan and galactomannan)
  • viral molecular assay
  • echocardiogram
  • CT scans of the chest, abdomen, and pelvis
More investigations to consider

Treatment algorithm


medium-to-high risk of complication or death: initial presentation

low risk of complication or death: initial presentation


antibiotic failure: fever beyond 3-5 days of treatment



Kenneth V. I. Rolston, MD

Internist and Professor of Medicine

Department of Infectious Diseases, Infection Control and Employee Health

Division of Internal Medicine

The University of Texas M.D. Anderson Cancer Center




KVIR has research grants from Merck, Inc., Shionogi, and JMI Laboratories for the performance of in-vitro studies of novel antimicrobial agents.

Lior Nesher, MD

Specialist in Infectious Disease & Internal Medicine

Infectious Disease Institute, Soroka Medical Center

Senior Lecturer, Faculty of Health Sciences

Ben-Gurion University of the Negev

Beer Sheba



LN has given two educational lectures sponsored by MSD.


Dr Kenneth Rolston and Dr Lior Nesher would like to gratefully acknowledge Dr Caron Jacobson and Dr Joseph Antin, previous contributors to this topic.


CJ and JA declare that they have no competing interests.

Peer reviewers

John Wingard, MD

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.

Matthew Falagas, MD, MSc, DSc


Alfa Institute of Biomedical Sciences





MF declares that he has no competing interests.

Ruth Pettengell, MBChB FRACP PhD

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 topic.

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