Neutropenic Fever and Cancer

Author: Michelle Lin, MD
Updated: 10/7/2011

Neutropenic Fever and Cancer

Chemotherapy causes neutropenia in 10-50% of patients with solid tumors and > 80% of patients with hematologic malignancies during chemotherapy cycle

Fever: ≥ 38.3 C (101 F) or ≥ 38.0 C (100.4 F) over 1-hour period

Neutropenia: Absolute neutrophil count < 500 cells/mm3

MASCC score

Multinational Association for Supportive Care in Cancer (MASCC) Score

Criteria Points
Burden of febrile neutropenia 5 (if mild) or 3 (if moderate)
No hypotension (SBP ≥ 90 mmHg) 5
Solid tumor or hematologic malignancy with no previous fungal infection 4
No dehydration requiring parenteral fluids 3
Outpatient status 3
Age <60 years 2

High Risk Patients (require admission)

  • MASCC score <21 OR
  • Any of clinical findings:
    • Prolonged (>7 days duration) and profound neutropenia (ANC ≤100 cells/mm3)
    • Hypotension
    • Pneumonia
    • New abdominal pain
    • Neurologic changes

Low Risk Patients (may be eligible for outpatient tx)

  • MASCC score ≥21
  • Brief (≤7 days duration) neutropenic periods and few co-morbidities


  • CBC, BUN/creatinine, electrolytes, AST/ALT, bilirubin
  • Chest xray, if respiratory signs or symptoms
  • 2 blood cultures (1 central line lumen if present + 1 peripheral vein, or 2 peripheral veins)

Antibiotic Treatment


  • Antipseudomonal beta-lactam (eg. cefipime, carbapenem, pip-tazo)
  • Vancomycin is not always indicated in cancer patients with a neutropenic fever.
  • Add vancomycin only if suspect catheter-related infection, skin/soft tissue infection, pneumonia, hemodynamic instability, colonization with MRSA/VRE/PCN-resistant Strep pneumoniae
  • For penicillin allergy: Ciprofloxacin + clindamycin, or aztremonam + vancomycin
  • Oral medication options for outpatient: Ciprofloxacin + amoxicillin-clavulanate

Central line-associated blood stream infection (CLABSI)

Remove catheter: Consider removal if any of following:

  • Caused by S. aureus, P. aeruginosa, fungi, mycobacteria
  • Tunnel infection
  • Pocket site infection
  • Septic thrombosis
  • Endocarditis
  • Sepsis with hemodynamic instability
  • Bacteremia despite ≥72 hours of antibiotics

Keep catheter and treat with antiobitics: If coagulase-negative staph


  • Fairefield AG et. al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer. 2010 update by the IDSA. Clinical Infectious Disease 2011; 52 (4): e56-93. [PubMed]