Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Management of a patient with acute lymphoblastic leukaemia presenting with febrile neutropenia:
- Immediate referral and assessment: Suspect neutropenic sepsis in patients undergoing anticancer treatment who become unwell and refer immediately for assessment in secondary or tertiary care as this is a medical emergency NICE CG151.
- Initial clinical assessment: Conduct a thorough history and examination, and perform investigations including full blood count, kidney and liver function tests, C-reactive protein, lactate, and blood cultures NICE CG151.
- Empiric antibiotic therapy: Start empiric intravenous antibiotic therapy immediately, preferably beta-lactam monotherapy with piperacillin with tazobactam unless contraindicated NICE CG151. Avoid aminoglycosides or glycopeptides initially unless specific indications exist NICE CG151.
- Risk assessment: Assess the patient’s risk of septic complications within 24 hours using a validated risk scoring system by a healthcare professional competent in managing anticancer treatment complications NICE CG151.
- Ongoing management: For high-risk patients, daily clinical review and reassessment of septic risk is required; do not switch empiric antibiotics unless clinical deterioration or microbiological indication occurs NICE CG151.
- Antibiotic duration and discharge: Continue inpatient empiric antibiotics if fever persists without alternative cause; discontinue antibiotics once neutropenic sepsis responds irrespective of neutrophil count. Switch to oral antibiotics and consider discharge only after reassessment confirms low risk and social circumstances are appropriate NICE CG151.
- Supportive care and facilities: Patients with acute lymphoblastic leukaemia at risk of prolonged neutropenia should be managed in facilities with appropriate isolation, rapid access to blood products, and emergency imaging NICE NG47.
- Prevention: Consider prophylactic fluoroquinolone (ciprofloxacin) during expected neutropenia periods in adults, monitoring for resistance and side effects NICE CG151.