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Some chemotherapy lowers the white cells that fight infection so much that a fever becomes dangerous. If your treatment carries a high risk of this, or you had an infection with low white cells on an earlier cycle, you may be given injections of a growth factor (G-CSF) after each cycle to help your white cells recover faster.
Primary prophylaxis with G-CSF is warranted when the regimen's risk of febrile neutropenia is about 20 per cent or higher and no equally effective and safe regimen without it exists (ASCO 2015; EORTC 2010 likewise for regimens at high risk, 20 per cent or more). For regimens with a risk of 10 to 20 per cent, patient factors such as age 65 or over decide (EORTC), and ASCO recommends prophylaxis for those at high risk from age, medical history, disease and the myelotoxicity of the regimen. After an episode of febrile neutropenia, G-CSF should be given in later cycles (secondary prophylaxis, EORTC). G-CSF is also used where it is part of a dose-dense or dose-intense regimen with proven benefit, or to keep dose intensity where cutting the dose worsens the outlook.
NICE CG151 frames the same rule from the other side: do not routinely offer G-CSF to prevent neutropenic sepsis unless it is an integral part of the regimen or needed to maintain dose intensity. Filgrastim (including biosimilars), lenograstim and pegfilgrastim are all effective (EORTC); pegfilgrastim is given once per cycle, which may avoid the short courses of daily injections seen in audits. ASCO advises dose-dense regimens needing G-CSF only in trials or where efficacy data are convincing. The AGIHO 2026 update confirms most of its 2014 recommendations and adds guidance for immunotherapy settings.
Why: The regimen's own risk is the starting point for deciding whether G-CSF is needed.
“We provide an expanded list of common chemotherapy regimens considered to have a high (≥20%) or intermediate (10-20%) risk of FN.”
Why: The same regimen is riskier in an older or frailer person, and risk changes from cycle to cycle.
“We recommend that patient-related adverse risk factors, such as elderly age (≥65 years) and neutrophil count be evaluated in the overall assessment of FN risk before administering each cycle of chemotherapy.”
Why: ASCO and EORTC set this as the level of risk at which preventing infection is worth the injections.
“Prophylactic use of CSFs to reduce the risk of febrile neutropenia is warranted when the risk of febrile neutropenia is approximately 20% or higher and no other equally effective and safe regimen that does not require CSFs is available.”
Why: A 10 to 20 per cent regimen becomes high risk in, for example, an older person or someone with other illnesses.
“When using a chemotherapy regimen associated with FN in 10-20% of patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN.”
Why: A person who has had one episode is likely to have another on the same treatment, and it avoids cutting or delaying the dose.
“It is important that after a previous episode of FN, patients receive prophylactic administration of G-CSF in subsequent cycles.”
Why: For most regimens the risk is too low for routine injections to help.
“Do not routinely offer G-CSF for the prevention of neutropenic sepsis in adults receiving chemotherapy unless they are receiving G-CSF as an integral part of the chemotherapy regimen or in order to maintain dose intensity.”
Why: All work; pegfilgrastim is one injection a cycle, which avoids courses of daily injections being stopped too early.
“Clinical evidence shows that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications where indicated.”
Why: Giving chemotherapy closer together is only worth its toxicity where it improves survival.
“Dose-dense regimens that require CSFs should only be used within an appropriately designed clinical trial or if supported by convincing efficacy data.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
ASCO (2015) and EORTC (2010) agree on the threshold: primary prophylaxis when the risk of febrile neutropenia is about 20 per cent or more, with patient factors deciding for regimens at 10 to 20 per cent, and secondary prophylaxis after an episode. NICE CG151 states the rule negatively (no routine G-CSF unless integral to the regimen or to maintain dose intensity) and recommends fluoroquinolone prophylaxis instead for adults expected to have severe neutropenia. The AGIHO 2026 update is the most recent guideline and says it confirms most of its 2014 recommendations; its grades were not read. All the international sources read in full or abstract are 2010 to 2015 apart from AGIHO, and NCCN's current version could not be read.
ASCO, Journal of Clinical Oncology 2015 · EORTC, European Journal of Cancer 2011 · NICE 2012 · AGIHO of the German Society of Hematology and Medical Oncology (DGHO), European Journal of Cancer 2026 · NCCN, Journal of the National Comprehensive Cancer Network 2022
Where it differs: NICE offers a fluoroquinolone during the expected period of neutropenia to adults with acute leukaemias, stem cell transplants or solid tumours in whom a neutrophil count of 0.5 × 10⁹ per litre or lower is expected from chemotherapy, points to the MHRA January 2024 advice on fluoroquinolone risks, and does not offer G-CSF routinely.
Evidence: NICE recommendations are not graded; the G-CSF recommendation dates from 2012.
Where it differs: Adds recommendations on G-CSF in immunotherapy settings and new G-CSF formulations, alongside the 2014 recommendations it confirms.
Evidence: Levels of evidence and strengths of recommendation set by ESCMID criteria after a literature search to December 2024; read as an abstract only, so the recommendations themselves are not given here.
Shares Suspected febrile neutropenia (neutropenic sepsis): the first hour, Filgrastim (G-CSF), Febrile neutropenia, Neutropenia and the tag protocol.
Shares Lenograstim, Pegfilgrastim, Filgrastim (G-CSF), Febrile neutropenia.
Shares Suspected febrile neutropenia (neutropenic sepsis): the first hour, Febrile neutropenia, Neutropenia, National Institute for Health and Care Excellence and the tag protocol.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares Suspected febrile neutropenia (neutropenic sepsis): the first hour, Febrile neutropenia and the tags protocol, supportive-care.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.