Febrile Neutropenia Đánh giá ban đầu

Cập nhật: 07 November 2025
Được đánh giá bởi

Nội dung của trang này:

Clinical Presentation

Nội dung của trang này:

Clinical Presentation

Clinical Presentation

The patient must be examined to determine the potential sites of infection and the causative organisms. Frequently, fever is the only indication of infection in the neutropenic patient.

 

Tiền sử bệnh

A complete history should be taken including underlying comorbidities, prior prophylactic antibiotic use, concomitant steroid use, time of last chemotherapy session, history of infections in the last 3 months, recent surgical procedures, exposure to pets, travel, tuberculosis exposure, etc. 

Khám thực thể

A thorough physical exam should be done especially at the most common sites of infection (eg oropharynx, sinuses, skin, lungs, gastrointestinal tract, perineum).

Screening

The risk assessment for complications of severe infection is done at the first sign of fever, guiding the type of empiric antibiotic treatment (oral versus intravenous [IV]), treatment setting (outpatient or inpatient) and the duration of antibiotic treatment. The risk for chemotherapy-induced febrile neutropenia depends on the dose intensity of the regimen used, together with patient-specific risk factors and treatment setting.

Tools Used to Identify Appropriate Site of Care

Talcott's Rules

Talcott’s rules is a predictive tool used to identify patients eligible for outpatient management. These are group I: Inpatients at time of onset of fever; group II: Outpatients with comorbidities requiring in-hospital management; group III: Outpatients without comorbidities but with uncontrolled cancer; and group IV: Cancer-free outpatients with no comorbidities who belong to low-risk patients

Multinational Association for Supportive Care in Cancer (MASCC) Score

The Multinational Association for Supportive Care in Cancer (MASCC) score is used to identify the risk of cancer patients for medical complications and the appropriate place of therapy. A patient's score of ≥21 indicates low risk for complications, and the patient may be a candidate for outpatient management. The scoring system is dependent on the presence of the following:

 Characteristic  Score
Burden of illness: No or mild symptoms*  5
Burden of illness: Moderate symptoms*   3
No hypotension (systolic blood pressure [BP] >90 mmHg)  5
No chronic obstructive pulmonary disease (COPD)  4
Solid tumor or hematological malignancy with no previous fungal infection  4
No dehydration requiring IV fluids  3
Outpatient status  3
Age <60 years  2

References: National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: prevention and treatment of cancer-related infections. Version 1.2025; Taplitz RA et al. Outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology (ASCO)/Infectious Diseases Society of American (IDSA) practice guideline update. Feb 2018.
*Burden of febrile neutropenia should be evaluated based on symptom severity: (5) mild or no symptoms; (3) moderate symptoms; (0) severe symptoms/moribund

Clinical Index of Stable Febrile Neutropenia (CISNE)

The Clinical Index of Stable Febrile Neutropenia (CISNE) is used for clinically stable patients with solid tumors, a history of chemotherapy (mild- to moderate-intensity) and access to a medical facility to determine the appropriate site of care.

The scoring depends on the following:

 Variable  Score
 Eastern Cooperative Oncology Group (ECOG) performance status ≥2  2
 COPD  1
 Chronic cardiovascular disease  1
 National Cancer Institute common toxicity criteria mucositis grade ≥2  1
 Monocytes <200/μL  1
 Stress-induced hyperglycemia  2

References: National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: prevention and treatment of cancer-related infections. Version 1.2025; Taplitz RA et al. Outpatient management of fever and neutropenia in adults treated for malignancy: ASCO/IDSA practice guideline update. Feb 2018.

The Clinical Index of Stable Febrile Neutropenia (CISNE) are: CISNE score of 0 for low risk; CISNE score of 1-2 for intermediate risk; and CISNE score of ≥3 for high risk.

Risk for Medical Complications and Severe Infections


 High Risk  Low Risk
  • MASCC score <21, presence of clinical judgment criteria, CISNE score ≥3, or Talcott's group 1-3
  • Presence of comorbidity or clinically unstable
  • Expected prolonged neutropenia (≥7 days) and ANC ≤100 neutrophils/μL
  • Uncontrolled/progressive cancer
  • Mucositis grade 3-4
  • Hepatic insufficiency (aminotransferase 5x upper limit of normal [ULN])
  • Renal insufficiency (creatinine clearance [CrCl] <30 mL/min)
  • History of allogeneic hematopoietic cell transplant (HCT) or immune/targeted therapies
  • Presence of pneumonia or other complex infections at time of presentation
  • Inpatient status at time of fever development
  • MASCC score ≥21, CISNE score <3, or Talcott's group 4
  • Absence of conditions included in the clinical judgment criteria
  • Neutropenia <7 days; ANC ≤100 neutrophils/μL; absolute monocyte count ≥100 cell/μL
  • Malignancy that is in remission, early evidence of bone marrow recovery
  • Normal X-ray
  • ECOG performance status 0-1
  • Near-to-normal renal and hepatic function tests
  • No IV catheter-site infection
  • Peak temperature <39°C
  • Outpatient status at time of fever development 

Reference: National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: prevention and treatment of cancer-related infections. Version 1.2025.

Clinical Judgment Criteria

The following comorbid conditions predetermine hospital admission in cancer patients with a MASCC score of ≥21 and reclassify patients under high-risk: Cardiovascular (hypotension, accelerated hypertension, presyncope/syncope, uncontrolled heart failure, arrhythmia, angina, bleeding, pericardial effusion); hematologic (ANC ≤100/μL [profound neutropenia] lasting ≥7 days, anemia, deep venous thrombosis, pulmonary embolism); gastrointestinal (nausea and vomiting, new-onset abdominal pain, diarrhea, inability to swallow oral medications, melena, hematochezia, hematemesis, ascites); neurologic (altered mental status, seizures, central nervous system infection, non-infectious meningitis, spinal cord compression, neurologic deficit); renal (creatinine clearance of <30 mL/min, oliguria, new-onset gross hematuria, urinary obstruction, nephrolithiasis, clinically relevant dehydration/electrolyte abnormalities/acidosis/alkalosis); respiratory (tachypnea, hypopnea, hypoxemia, hypercarbia, pneumothorax, pleural effusion, pneumonia, chronic lung disease or new pulmonary infiltrates); infectious (intravascular catheter infection, with clear anatomic site of infection (pneumonia, cellulitis), evidence of sepsis, antimicrobial therapy ≤72 hours prior to consultation, allergy to oral antimicrobials); and hepatic (aminotransferase levels >5x the normal value, worsening aminotransferase levels, bilirubin >2 mg/dL).

Risk Group Based on Chemotherapy Regimen

The risk groups that are based on chemotherapy regimen include: High-risk group with >20% risk of febrile neutropenia; intermediate-risk group with 10-20% risk of febrile neutropenia; and low-risk group with <10% risk of febrile neutropenia.