Febrile Neutropenia
Description General Measures Medicine Treatment Referral/Consultation D70 DESCRIPTION Febrile neutropenia is conventionally defined as an absolute neutrophil count of <0.5 x 10 9 /L with a temperature of greater than 38°C for >1 hour or a single temperature of 38.3°C, but any neutropaenic patient showing clinical signs of sepsis should be investigated. Note: - This is a medical emergen
D70
DESCRIPTION
Febrile neutropenia is conventionally defined as an absolute neutrophil count of <0.5 x 109 /L with a temperature of greater than 38°C for >1 hour or a single temperature of 38.3°C, but any neutropaenic patient showing clinical signs of sepsis should be investigated.
Note:
- This is a medical emergency: A minor infection may progress rapidly, with patients developing features of severe sepsis (multi-organ failure and/or hypotension). It is crucial to monitor and treat patients for signs and symptoms of infection.
- Cultures should be obtained for appropriate microbiological testing prior to starting empirical antimicrobial therapy.
- It is critical to recognise neutropenic fever early and to initiate empiric systemic antibacterial therapy promptly to reduce the risk of severe sepsis and mortality.
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GENERAL MEASURES
- Treat the underlying cause of neutropenia, if applicable.
- Withdraw any medication that may cause neutropenia, e.g. carbimazole, clozapine, co-trimoxazole, penicillins, carbamazepine, valproate.
- Consider removing central IV line. Once culture results are available, adjust treatment to the most appropriate narrow spectrum agent.
MEDICINE TREATMENT
For patients with febrile neutropenia within 48 hours of admission:
- Ceftriaxone, IV, 1 g daily.
AND
- Gentamicin, IV, 6 mg/kg daily. (See Appendix II: Prescribing Information for Specific Medicines, for guidance on prescribing).
If IV line, skin infection is suspected as the cause:
ADD:
- Vancomycin, IV, 25–30 mg/kg as a loading dose. Follow with 15–20 mg/kg/dose 12 hourly. (See Appendix II: Prescribing Information for Specific Medicines, for guidance for prescribing and monitoring).
For patients with febrile neutropenia that develop after 48 hours of admission:
There is an increased risk of a hospital acquired infection. The choice of antibiotic will depend on local susceptibility patterns.
Regimen 1:
- Carbapenem with activity against Pseudomonas, e.g.:
- Meropenem, IV, 1 g 8 hourly.
OR
- Imipenem/cilastatin, IV, 1000/1000 mg 8 hourly.
Note:
Ertapenem is not recommended as it is not effective for Pseudomonas species, which are important pathogens in this setting.
OR
Regimen 2:
- Piperacillin/tazobactam, IV, 4.5 g 6 hourly.
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AND
- Amikacin, IV, 15 mg/kg daily. (See Appendix II: Prescribing Information for Specific Medicines, for individual dosing and monitoring for response and toxicity).
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OR
Regimen 3:
- Cefepime, IV, 2 g 12 hourly.
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If no response to antibiotics after 5–7 days: (In discussion with a Clinical Haematologist or Infectious Disease specialist)
ADD:
- Amphotericin B, IV, 1 mg/kg daily in dextrose 5% over 4 hours.
- Ensure adequate hydration to minimise nephrotoxicity (See Appendix II: Prescribing Information for Specific Medicines, for preventing, monitoring and management of toxicity).
Duration of therapy:
- If neutrophil count increases to >0.5 x 109 /L, continue for 2 days after fever has settled.
- If neutrophil count remains ≤0.5 x 109 /L, continue for 7 days after fever has settled.
REFERRAL/CONSULTATION
All cases – consult with haematologist/oncologist.
Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level_Version 1_30 March 2026
Chapter 2: Blood and Blood Forming Organs; 2.2 Febrile Neutropenia