Neutropaenic sepsis

Overview

• neutropenic sepsis is a potentially fatal complication of anticancer treatment (particularly chemotherapy) and systemic immunosuppression requiring emergency assessment and broad-spectrum parenteral antimicrobials (1, 2)
• mortality rates range between 2% and 21% in adults; prompt inpatient IV antibiotic therapy has reduced morbidity and mortality, with intensive care required in under 5% of cases in England (1)
• guidance in NICE NG253 aligns neutropenic sepsis pathways with NEWS2 risk tiers and updated antimicrobial timelines (2)

Definition neutropenic sepsis is diagnosed in patients having anticancer treatment whose neutrophil count is <= 0.5 x 10^9/L and who have either (1):

• a temperature higher than 38.0°C
• other signs or symptoms consistent with clinically significant sepsis (for example hypothermia < 36.0°C, rigors, unexplainable malaise, or isolated hypotension)

Primary Care Recognition and Immediate Referral

• suspect neutropenic sepsis in any patient currently undergoing anticancer treatment (or within 6 weeks of completion) who becomes acutely unwell (1)
• refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care via emergency 999 transfer (1)
• do not wait for blood test results or neutrophil confirmation in primary care before arranging transfer (1)
• if transport or hospital admission is delayed by > 1 hour, administer pre-hospital broad-spectrum IV/IM antibiotics where local pathways permit (2)

Emergency Assessment and Secondary Care Diagnostics treat suspected neutropenic sepsis as an acute medical emergency and obtain immediate diagnostics (1):

• initial assessment: history, physical examination, and NEWS2 calculation (2)
• mandatory laboratory investigations: FBC, U&Es, LFTs (including albumin), CRP, lactate, and peripheral blood cultures (1)
• secondary testing: obtain additional peripheral blood cultures via central venous access devices where present, and perform urinalysis in children aged under 5 years (1)
• biomarker testing: consider procalcitonin (PCT) testing alongside standard bloods to support antimicrobial stewardship (2)
• do not delay first-dose empirical antibiotics for diagnostic blood culture or biomarker results (1)

Empiric Antimicrobial and Resuscitation Protocol

Antibiotic Selection

• offer IV beta-lactam monotherapy with piperacillin with tazobactam as initial empiric antibiotic therapy unless patient-specific or local microbiological contraindications exist (1)
• do not offer an aminoglycoside (either as monotherapy or dual therapy) for initial empiric treatment unless indicated by specific patient factors or local resistance patterns (1)

Risk Stratification and Escalation

• high risk (NEWS2 >= 7 or unstable): initiate empiric broad-spectrum IV antibiotics within 1 hour of presentation and begin fluid resuscitation using 250 ml isotonic crystalloid boluses if hypotensive or lactate > 2 mmol/L (2)
• moderate/low risk: review by FY2+ clinician or specialist haematology practitioner within 1 hour; evaluate suitability for outpatient pathways using validated scoring tools (for example MASCC) in consultation with oncology (1, 2)

Prophylaxis and Prevention

• fluoroquinolone prophylaxis: offer a fluoroquinolone during anticipated neutropenia (neutrophil count <= 0.5 x 10^9/L) only in adults with acute leukaemias, stem cell transplants, or solid tumours receiving chemotherapy (1)
• antibiotic resistance monitoring: treatment facilities using fluoroquinolone prophylaxis must routinely monitor local resistance patterns (1)
• G-CSF usage: do not routinely offer granulocyte-colony stimulating factor (G-CSF) for prevention of neutropenic sepsis unless integral to the chemotherapy regimen or required to maintain dose intensity (1)

References

1. National Institute for Health and Care Excellence (NICE). Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients. Clinical Guideline [CG151].
2. National Institute for Health and Care Excellence (NICE). Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). Published Nov 2025, updated Sep 2026.