# Suspected febrile neutropenia (neutropenic sepsis): the first hour

Source: https://onco.cc/protocols/febrile-neutropenia-first-hour/  
OnCo record `febrile-neutropenia-first-hour` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Anyone having cancer treatment who feels unwell, with or without a high temperature, should ring their 24-hour cancer line and be seen in hospital straight away. There they should be given a strong antibiotic through a drip within about an hour, without waiting for the blood count to come back.

## Summary

Suspect neutropenic sepsis in any adult having anticancer treatment who becomes unwell (NICE CG151 1.3.1.1); NICE NG253 widens this to systemic anticancer treatment within the last 30 days and to people on immunosuppressants, and warns that people having treatment for cancer may not develop a raised temperature. NICE confirms the diagnosis later, at a neutrophil count of 0.5 × 10⁹/L or lower with a temperature higher than 38 °C or other signs of clinically significant sepsis; SEOM uses a temperature above 38 °C or clinical signs of sepsis with neutrophils below 500/mm³, or below 1000/mm³ before the nadir.

Treatment does not wait for the count. NICE says to offer empiric antibiotics immediately and sets no clock, because its committee found the evidence on timing very low quality; ASCO/IDSA (2018) endorse the first dose within 1 hour of triage, and SEOM (2018) within the first hour of arrival in the emergency department, after cultures. NICE's first choice is piperacillin with tazobactam alone, with no routine aminoglycoside or glycopeptide; SEOM allows any anti-pseudomonal beta-lactam and adds amikacin, preferably with a carbapenem, when severity criteria are met. Bloods include full blood count, renal and liver function with albumin, C-reactive protein, lactate and blood cultures, with a peripheral culture as well as a line culture where there is a central venous device, which stays in.

Within 24 hours a competent clinician scores the risk of septic complications with a validated tool (MASCC; CISNE for stable patients with solid tumours on moderate-intensity chemotherapy in SEOM). A MASCC score of 21 or more marks those who may go home on oral antibiotics; under 21 is high risk and stays on the standard pathway. Under NG253, a high-risk patient who does not respond within 1 hour of any intervention needs a senior decision maker in person and a critical care discussion.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: neutropenic sepsis first hour; febrile neutropenia door-to-needle; neutropenic fever emergency management; suspected neutropenic sepsis
- Tags: protocol; neutropenic-sepsis; acute-oncology

## Connected records

- ideas: [Acute oncology assessment units so sick cancer patients bypass the emergency department](https://onco.cc/ideas/idea-acc-acute-oncology-assessment-units/), [Hospital-at-home for oncology: treating low-risk febrile neutropenia and dehydration at home](https://onco.cc/ideas/idea-acc-hospital-at-home-oncology/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports)](https://onco.cc/technologies/implanted-ports/), [Peripherally inserted central catheters (PICC lines)](https://onco.cc/technologies/picc-lines/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [Multinational Association of Supportive Care in Cancer](https://onco.cc/institutions/mascc/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Central venous access (port, PICC line)](https://onco.cc/terms/central-venous-access/), [Febrile neutropenia](https://onco.cc/terms/febrile-neutropenia/), [Neutropenia](https://onco.cc/terms/neutropenia/), [Neutropenic sepsis: the temperature rule and the 999 signs](https://onco.cc/terms/neutropenic-sepsis-breast-chemotherapy/)
- protocols: [Acute oncology telephone triage: the 24-hour helpline and the UKONS red, amber and green grading](https://onco.cc/protocols/acute-oncology-telephone-triage/), [Antibacterial (fluoroquinolone) prophylaxis during expected severe neutropenia](https://onco.cc/protocols/antibacterial-prophylaxis-in-neutropenia/), [Cytokine release syndrome after CAR T-cell therapy: ASTCT grading, tocilizumab and steroids](https://onco.cc/protocols/crs-grading-and-management/), [Diarrhoea from chemotherapy, targeted therapy and radiotherapy: grading, loperamide, octreotide and when to admit](https://onco.cc/protocols/treatment-induced-diarrhoea-grading-and-management/), [Fever and neutropenia in children with cancer or after stem cell transplant](https://onco.cc/protocols/paediatric-fever-and-neutropenia/), [G-CSF prophylaxis by febrile neutropenia risk](https://onco.cc/protocols/g-csf-prophylaxis-by-febrile-neutropenia-risk/), [Irinotecan: early cholinergic syndrome and late diarrhoea](https://onco.cc/protocols/irinotecan-early-cholinergic-syndrome-and-late-diarrhoea/), [Neutropenic enterocolitis (typhlitis): imaging, cultures, antibiotics and conservative care](https://onco.cc/protocols/neutropenic-enterocolitis/), [Suspected central line infection in a person with cancer: paired blood cultures, first antibiotics and line removal or salvage](https://onco.cc/protocols/suspected-central-line-infection/)

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