Febrile Neutropenia: Risk Stratification and Empiric

Febrile neutropenia risk stratification guides the intensity of treatment and determines inpatient vs outpatient management. The Multinational Association for Supportive Care in Cancer (MASCC) score is the validated tool for risk assessment, scoring burden of illness, hypotension absence, no COPD, solid tumor or no prior fungal infection, outpatient status, no dehydration, and age <60 years — a score of 21 or higher identifies low-risk patients with <5% complication rate who may be candidates for oral outpatient therapy. High-risk features include anticipated prolonged neutropenia (>7 days), ANC <100, MASCC score <21, significant comorbidities (hepatic or renal insufficiency, uncontrolled cancer), hemodynamic instability, or mucosal barrier injury. Empiric antibiotic selection follows an antipseudomonal strategy because Pseudomonas aeruginosa bacteremia carries 30-40% mortality in neutropenic patients. Monotherapy with an antipseudomonal beta-lactam (cefepime, piperacillin-tazobactam, or meropenem) is standard first-line. Vancomycin is added only for specific indications: hemodynamic instability, pneumonia, skin/soft tissue infection, catheter-related infection, or known MRSA colonization. Empiric antifungal therapy (caspofungin or voriconazole) is initiated if fever persists beyond 4-7 days of appropriate antibacterial therapy, as invasive aspergillosis and candidemia become increasingly likely with prolonged...