For a patient receiving cancer chemotherapy, a simple fever can be the first sign of a life-threatening infection. Neutropenic sepsis (also called febrile neutropenia when fever is present) is one of the most common oncology emergencies. It can kill quickly, but prompt recognition and early antibiotics save lives. Nurses on oncology units, emergency departments, general medical wards and chemotherapy helplines are often the first to pick it up.
What is neutropenia?
Neutrophils are the white blood cells that fight bacterial and fungal infection. Many chemotherapy drugs damage the bone marrow, so the neutrophil count falls, usually reaching its lowest point (the “nadir”) around 7 to 14 days after treatment, although timing varies by regimen.
- Neutropenia is usually defined as a neutrophil count below 1.5 × 10⁹/L.
- Severe neutropenia is a count of 0.5 × 10⁹/L or lower. This is the level most guidelines use to define neutropenic sepsis.
With so few neutrophils, the usual signs of infection, such as pus, swelling and redness, may be absent. A patient may have a serious pneumonia with a clear chest X-ray, or a severe line infection with almost nothing to see. Fever may be the only clue.
Who is at risk?
- Anyone who has had systemic anti-cancer therapy (chemotherapy, some targeted drugs) in the last 6 weeks
- Patients with blood cancers such as leukaemia and lymphoma, and after stem cell transplant
- People with central venous catheters (PICC lines, ports, Hickman lines)
- Patients with mucositis (mouth ulcers), which breaks the body’s barriers
- Older patients and those with other illnesses such as diabetes, heart or lung disease
- Patients receiving radiotherapy to large areas of bone marrow
Recognising neutropenic sepsis
The UK NICE guideline on neutropenic sepsis (CG151) advises that sepsis should be suspected in any patient having anti-cancer treatment who becomes unwell. Do not wait for a high fever.
Suspect it if a patient who has had chemotherapy recently has:
- A temperature of 38°C or higher
- Or any symptoms or signs of sepsis even without fever, such as feeling generally unwell, shivering or rigors, confusion, fast breathing, a fast heart rate, low blood pressure, reduced urine output or mottled skin
Important points:
- Some patients cannot mount a fever, especially older adults and those on steroids. Paracetamol may also mask a temperature.
- Hypothermia (temperature below 36°C) can also be a sign of sepsis.
- Rigors after flushing a central line are a red flag for line infection.
The first hour: what nurses do
The key target is to give intravenous broad-spectrum antibiotics within one hour of the patient arriving or of sepsis being suspected. This is a “door-to-needle” time that many hospitals audit. Don’t wait for the full blood count result before giving antibiotics.
- Triage as an emergency. A patient who phones a chemotherapy helpline with fever should be told to come straight to hospital. In the emergency department, they should be seen immediately, not left in the waiting room.
- Protect them from infection. Place the patient in a side room if possible. Use strict hand hygiene. Keep them away from people with coughs and diarrhoea.
- Full set of observations and an early warning score (for example NEWS2). Escalate immediately if the score is high.
- Alert the doctor using SBAR: “This patient had chemotherapy 9 days ago, temperature 38.4°C, pulse 118. I suspect neutropenic sepsis and need antibiotics prescribed now.”
- Get IV access and take bloods: full blood count, urea and electrolytes, liver function, C-reactive protein, lactate and blood cultures. If there is a central line, take cultures from the line and a peripheral vein.
- Give IV antibiotics as prescribed, within the hour. Many protocols use piperacillin-tazobactam (or a local alternative for penicillin allergy) as initial empirical therapy.
- Start IV fluids if the patient is hypotensive or has a raised lactate, as prescribed.
- Monitor urine output. A catheter may be needed in sick patients.
- Collect other samples as indicated: urine, sputum, stool, swabs of wounds or line sites. Request a chest X-ray if there are respiratory symptoms.
- Document the times of arrival, assessment and antibiotic administration.
What not to do
- Don’t take rectal temperatures or give suppositories or enemas. These can damage the bowel lining and let bacteria into the bloodstream.
- Don’t delay antibiotics to wait for blood results, a doctor’s review or a bed on the oncology ward.
- Don’t dismiss mild symptoms in a patient who “looks well”. Neutropenic patients can deteriorate very quickly.
- Avoid unnecessary invasive procedures, such as urinary catheters, unless clinically needed.
Ongoing nursing care
- Frequent observations: at least hourly while unstable, then as directed.
- Fluid balance and daily weights.
- Mouth care with soft toothbrushes and prescribed mouthwashes to manage mucositis.
- Line care: inspect central line sites every shift and follow aseptic technique strictly.
- Skin care: watch for pressure damage, perianal skin breaks and rashes.
- Nutrition: offer food that is safely prepared and well cooked. Some units advise avoiding high-risk foods such as unpasteurised dairy and raw eggs.
- Psychological support: an admission with sepsis can frighten patients and families, who may fear it means the cancer is winning. Explain what is happening and why.
The medical team will review antibiotics as culture results return. Some lower-risk patients may switch to oral antibiotics and go home early after assessment with a risk score such as MASCC, while higher-risk patients may need intensive care. Growth factor injections (G-CSF) are sometimes used to speed neutrophil recovery.
Patient education: the most powerful prevention
Before every cycle of chemotherapy, nurses should make sure patients and carers know:
- How to take their temperature with a reliable digital thermometer, and to check it if they feel unwell.
- To call the 24-hour helpline or come to hospital immediately if their temperature is 38°C or higher, or if they feel shivery, unwell, confused or breathless, even at night.
- Not to take paracetamol or ibuprofen for a fever before calling, as it can hide the warning sign.
- Simple infection prevention: hand washing, avoiding people with infections, food hygiene and good mouth care.
- To carry an alert card that says they are on chemotherapy, so emergency staff act quickly.
In many low- and middle-income countries, patients may travel long distances for chemotherapy and have no helpline. In these settings, nurses can help by giving written instructions in local languages, the phone number of a nurse or doctor, and a clear plan for where to go if fever develops.
Key points to remember
- Any patient within 6 weeks of chemotherapy who has a fever of 38°C or more, or who simply feels unwell, should be treated as possible neutropenic sepsis.
- Give IV antibiotics within 1 hour. Don’t wait for the blood count.
- Take blood cultures from both the line and a peripheral vein.
- Avoid rectal procedures.
- Educate every patient before every cycle.
Neutropenic sepsis is a race against time. When nurses recognise it early and act fast, patients survive and can continue the cancer treatment they need.