# Fever and neutropenia in children with cancer or after stem cell transplant

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

## TL;DR

A child having cancer treatment who gets a fever, or seems unwell, needs to be seen in hospital straight away, using the team's number. There blood cultures are taken from every channel of the central line and one strong antibiotic is started through a drip. Children at low risk may finish at home or by mouth, and antibiotics can often stop after two days if cultures stay clear.

## Summary

The International Pediatric Fever and Neutropenia Guideline Panel's 2023 update (79 randomised trials, GRADE) covers patients aged 0 to 18 receiving chemotherapy for cancer and recipients of haematopoietic cell transplant, and is endorsed by the Children's Oncology Group. Adopt a validated paediatric risk stratification rule (strong, low). Take blood cultures from all lumens of a central venous catheter at onset (strong, low); a peripheral culture alongside is conditional, because it adds 12% of bacteraemias but causes pain and contaminants. Urine where a clean-catch specimen is readily available (conditional); chest radiograph only with respiratory signs (strong, moderate).

High-risk episodes get monotherapy with an antipseudomonal beta-lactam, a fourth-generation cephalosporin or a carbapenem (strong, high); a second anti-Gram-negative agent or a glycopeptide is reserved for instability, suspected resistance or high-resistance centres. A new good practice statement asks for therapy as soon as possible in the clinically unstable child, ideally much sooner than an hour after presentation; the panel could not agree a time target for well, low-risk children. Low-risk episodes may be managed as outpatients or with oral antibiotics where the infrastructure allows (conditional). Antibiotics stop at 48 hours with negative cultures once the child has been well and afebrile for 24 hours, with marrow recovery (strong) or, new in 2023, without it in low-risk FN (conditional). For fever lasting 96 hours or more in children at high risk of invasive fungal disease: CT chest (strong), consider abdominal ultrasound, do not use beta-D-glucan or fungal PCR, and start caspofungin or liposomal amphotericin B (strong, high) unless a pre-emptive approach is chosen. NICE CG151, for any age, recommends piperacillin with tazobactam alone first and names the modified Alexander rule for children under 18.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: paediatric febrile neutropenia; pediatric fever and neutropenia; neutropenic fever in children; paediatric neutropenic sepsis; FN in children
- Tags: protocol; paediatric; neutropenic-sepsis

## Connected records

- protocols: [Antibacterial (fluoroquinolone) prophylaxis during expected severe neutropenia](https://onco.cc/protocols/antibacterial-prophylaxis-in-neutropenia/), [Antifungal prophylaxis for people at high risk of invasive fungal infection](https://onco.cc/protocols/antifungal-prophylaxis-in-haematology/), [Clostridioides difficile infection in children with cancer or after stem cell transplant](https://onco.cc/protocols/paediatric-clostridioides-difficile/), [Suspected febrile neutropenia (neutropenic sepsis): the first hour](https://onco.cc/protocols/febrile-neutropenia-first-hour/)
- cancers: [Acute lymphoblastic leukaemia](https://onco.cc/cancers/all-leukemia/), [Acute myeloid leukaemia](https://onco.cc/cancers/aml/), [Childhood cancers (all types)](https://onco.cc/cancers/childhood-cancers/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Allogeneic stem cell transplantation](https://onco.cc/technologies/allogeneic-hsct/), [Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports)](https://onco.cc/technologies/implanted-ports/)
- companies: [Children's Oncology Group (COG)](https://onco.cc/companies/childrens-oncology-group/)
- institutions: [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/)

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