Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Stabilization and time zero
Airway and breathing threats
Altered mental status
Respiratory distress
Hypoxemia
Circulation threats
Hypotension
New or worsening tachycardia
Poor perfusion
Neutropenic sepsis trigger
Fever with suspected infection and ANC < 0.5 x 10^9/L
Fever with expected ANC < 0.5 x 10^9/L within 48 hours
Antibiotic timing target
First dose within 60 minutes of ED arrival for suspected neutropenic sepsis
Door to antibiotic metric documentation
Early source control mindset
Suspected catheter infection
Suspected obstructed urinary tract
Suspected necrotizing soft tissue infection
Sepsis bundle in immunocompromised host
Sepsis recognition and perfusion
Hemodynamic monitoring
Continuous pulse oximetry
Telemetry
Frequent blood pressure cycling
Lactate strategy
Initial lactate for suspected sepsis
Repeat lactate if elevated or clinical deterioration
Fluids and pressors
If hypotension or lactate elevation, crystalloid bolus guided by response
If persistent hypotension, norepinephrine first line
Early ICU pathway triggers
Vasopressor requirement
Rising lactate
Worsening mental status
Escalating oxygen requirement
Infection control and isolation
Exposure and transmission precautions
Respiratory virus season precautions
Masking and droplet precautions if respiratory symptoms
Rapid respiratory viral testing per local policy
High risk mucositis and diarrhea precautions
Contact precautions if concern for infectious diarrhea
C difficile testing criteria
History
Key history elements
Presentation frame
Fever definition context
Single oral temperature >= 38.3 C
Temperature >= 38.0 C sustained for >= 1 hour
Symptom localization
Respiratory symptoms
Urinary symptoms
Abdominal pain or diarrhea
Skin or soft tissue pain
Headache or meningismus
Time course
Onset relative to last chemotherapy
Duration of fever
Immunocompromise details
Malignancy and therapy
Hematologic malignancy
Solid tumor chemotherapy
Stem cell transplant status and timing
Neutropenia context
Prior ANC nadir pattern
Expected duration of neutropenia > 7 days
Medications
Recent antibiotics within 90 days
Prophylaxis
Fluoroquinolone prophylaxis
Antifungal prophylaxis
Antiviral prophylaxis
Corticosteroid exposure
Infection risk modifiers
Indwelling devices
Central venous catheter type and recent access
Port site symptoms
Urinary catheter
Mucosal barrier injury
Oral mucositis
Severe diarrhea
Prior resistant organisms
MRSA colonization or infection
ESBL or CRE history
Pseudomonas history
VRE history
Red flags for complicated infection
Rigors
Confusion
Hypotension symptoms
New rash or skin pain out of proportion
Severe focal abdominal pain
Severe headache
Risk stratification inputs
Low risk outpatient screen inputs
Clinical stability
No hypotension
No hypoxemia
Reliable follow up and support
Caregiver availability
Transportation access
Oral intake ability
No persistent vomiting
No severe mucositis preventing PO
High risk features
Anticipated prolonged neutropenia
ANC < 0.1 x 10^9/L
Duration > 7 days expected
Significant comorbidity
COPD with oxygen needs
Heart failure with decompensation risk
Cirrhosis
CKD with dialysis
Uncontrolled cancer burden
Progressive disease
Recent hospitalization
Unstable social situation
No rapid return access
Poor adherence history
Physical Exam
Focused exam domains
Vital signs and perfusion
Temperature trend
Antipyretic use masking fever
Hypothermia as severe infection marker
Shock indicators
Narrow pulse pressure
Cool extremities
Delayed capillary refill
Respiratory status
Work of breathing
Oxygen saturation
Head to toe infection survey
Oropharynx
Mucositis grade
Thrush
Lungs
Focal crackles
Pleural findings
Abdomen
Localized tenderness
Peritoneal signs
Perineum
Perirectal pain
Skin breakdown
Skin and soft tissue
Cellulitis
Necrotizing infection clues
Line and port sites
Erythema
Tenderness
Drainage
Neuro exam
Meningismus
Focal deficits
PITFALLS
Blunted inflammatory response
Absence of localizing signs despite invasive infection
Minimal sputum despite pneumonia
Steroids and antipyretics masking severity
Afebrile sepsis in neutropenia
Relative hypotension compared with baseline
Differential Diagnosis
Life threatening
Immediate threats
Neutropenic sepsis
Bacteremia
Septic shock
Pneumonia
Typical bacterial
Opportunistic
Central line associated bloodstream infection
Tunnel infection
Port infection
Typhlitis
Neutropenic enterocolitis
Bowel ischemia or perforation
Meningitis or encephalitis
Bacterial
Viral
Necrotizing soft tissue infection
Common infectious sources
Bacterial sources
Urinary tract infection
Pyelonephritis
Obstructed infected stone
Skin and soft tissue infection
Cellulitis
Abscess
Intra abdominal infection
Cholecystitis
Appendicitis
Viral sources
Respiratory viruses
Influenza
RSV
SARS CoV 2
HSV or VZV
Disseminated infection risk
Fungal sources
Invasive candidiasis
Persistent fever on broad spectrum antibiotics
Mold infection
Prolonged neutropenia with pulmonary symptoms
Noninfectious mimics
Therapy and malignancy related
Drug fever
Recent antibiotic exposure
G CSF associated fever
Tumor fever
Progressive cancer burden
Thrombosis
Pulmonary embolism
Catheter associated thrombosis
Transfusion reaction
Recent blood product exposure
Laboratory Tests
Core labs and interpretation
Baseline severity and organ function
CBC with differential
ANC calculation
Severe neutropenia ANC < 0.5 x 10^9/L
Profound neutropenia ANC < 0.1 x 10^9/L
Electrolytes and renal function
Sodium mmol/L
Potassium mmol/L
Creatinine trend for dosing
Liver enzymes and bilirubin
Hepatic dysfunction for drug selection
Lactate
Sepsis marker
Resuscitation response marker
Blood glucose mmol/L
Stress hyperglycemia
Hypoglycemia as severe illness marker
Microbiology
Blood cultures
Two sets from separate sites
Peripheral set preferred if feasible
Line set if central access present
Culture timing
Before antibiotics if no delay in first dose
After antibiotics if unstable and access delays
Urinalysis and urine culture
Indications
Urinary symptoms
No clear source
Pitfalls
Minimal pyuria in neutropenia
Respiratory testing
Viral PCR panel per local pathways
Respiratory symptoms
Known exposure outbreak
Sputum culture considerations
Productive cough
Intubated patient
Stool testing
C difficile NAAT or toxin testing criteria
New significant diarrhea
Recent antibiotic exposure
GI pathogen panel in severe diarrhea per local policy
Additional targeted labs
Complication and co infection markers
Procalcitonin
Adjunct only
Limited rule out utility in immunocompromised
Coagulation studies
DIC concern
Liver dysfunction concern
Type and screen
Anticipated transfusion
Active bleeding
Antifungal and opportunistic workup
Serum beta D glucan
Persistent fever with candidiasis concern
False positives with IVIG and certain antibiotics
Serum galactomannan
Prolonged neutropenia with pulmonary findings
Reduced sensitivity on mold active prophylaxis
Diagnostic Tests
Scoring Systems
Outpatient eligibility risk tools
MASCC risk index
Low risk threshold commonly >= 21
Predicts low complication risk
CISNE score
Solid tumor patients
Helps identify occult high risk among seemingly stable patients
Limitations and cautions
Tool use as adjunct to clinical judgment
Not a substitute for instability assessment
MRI
MRI role
CNS infection evaluation when CT non diagnostic
Encephalitis concern
Focal neurologic deficits
Spine infection evaluation
Back pain with neurologic symptoms
Epidural abscess concern
Constraints
Hemodynamic instability limiting MRI transport
Time to imaging delaying antibiotics
CT
CT chest
Pulmonary source evaluation
Abnormal CXR or persistent symptoms
High risk for atypical and fungal pneumonia
Neutropenic pneumonia pitfalls
Normal early chest x ray with CT positive findings
CT abdomen and pelvis
Typhlitis evaluation
Abdominal pain with neutropenia
Diarrhea with severe neutropenia
Complication screening
Abscess
Obstruction
Perforation
CT head
CNS process screen before lumbar puncture when indicated
New focal deficit
New seizure
Significant altered mental status
Ultrasound
POCUS applications
Shock evaluation
IVC assessment as adjunct
Cardiac function estimate
Pericardial effusion
Line associated issues
Upper extremity DVT around catheter
Biliary and urinary obstruction
Hydronephrosis
Cholecystitis findings
Disposition
Level of care decisions
Admission default
High risk febrile neutropenia
Expected neutropenia > 7 days
ANC < 0.1 x 10^9/L
Significant comorbidity
Unstable physiology
Hypotension
New hypoxemia
Rising lactate
ICU indications
Septic shock
Vasopressor requirement
Persistent hypotension after fluids
Respiratory failure risk
High flow oxygen requirement
Impending intubation
Rapidly progressive organ dysfunction
Acute kidney injury with oliguria
Severe encephalopathy
Outpatient management pathway
Outpatient criteria bundle
Low risk profile
MASCC high score or CISNE low score supportive
No expected prolonged neutropenia
Clinical stability
Stable vitals after ED observation
No new oxygen requirement
No uncontrolled source concern
No pneumonia requiring IV therapy
No abdominal peritonitis
Logistics
Reliable follow up within 24 to 48 hours
Ability to obtain and take oral antibiotics
Outpatient failure triggers
Persistent fever beyond 48 to 72 hours
New rigors
Any hypotension
Worsening respiratory symptoms
Treatment
Empiric antibiotics
Antibiotic strategy principles
Broad spectrum anti pseudomonal coverage
Gram negative sepsis risk including Pseudomonas
First dose target within 60 minutes
Regimen selection drivers
Hemodynamic status
Local antibiogram
Prior resistant organisms
High risk inpatient IV monotherapy options
Cefepime IV
2 g IV every 8 hours if normal renal function
Renal dose adjustment per local protocol
Neurotoxicity risk in renal impairment
Piperacillin tazobactam IV
4.5 g IV every 6 hours if normal renal function
Extended infusion option per local protocol
Anaerobe coverage benefit in abdominal source concern
Meropenem IV
1 g IV every 8 hours if normal renal function
ESBL coverage
Seizure risk consideration in CNS disease history
Escalation to dual coverage in shock or high resistance settings
Add aminoglycoside option
Gentamicin IV
5 to 7 mg/kg IV once daily dosing strategy
Therapeutic drug monitoring requirement
Nephrotoxicity and ototoxicity risk
Add fluoroquinolone option if not on prophylaxis and susceptibility supports
Ciprofloxacin IV
400 mg IV every 8 to 12 hours if normal renal function
QT prolongation risk
MRSA and gram positive add on criteria
Vancomycin indications
Suspected catheter related infection
Skin or soft tissue infection
Pneumonia
Hemodynamic instability
Known MRSA colonization with severe presentation
Vancomycin dosing
15 to 20 mg/kg IV per dose using actual body weight
Trough or AUC monitoring per local protocol
Renal dose adjustment requirement
Alternatives when vancomycin unsuitable
Linezolid IV or PO
600 mg every 12 hours
Thrombocytopenia risk with prolonged use
Daptomycin IV
6 to 10 mg/kg daily depending on severity
Not for pneumonia
Low risk outpatient antibiotics
Oral regimens when outpatient criteria met
Ciprofloxacin plus amoxicillin clavulanate
Ciprofloxacin 500 to 750 mg PO every 12 hours
Amoxicillin clavulanate 875 mg PO every 12 hours
Penicillin allergy alternative for beta lactam component per local guidance
Levofloxacin monotherapy in selected settings
750 mg PO daily
Avoid if fluoroquinolone prophylaxis
Local resistance constraints
First dose in ED
Oral first dose observed
Tolerance verification
Early adverse reaction screen
Antifungal and antiviral considerations
Persistent fever strategy
Empiric antifungal trigger
Persistent fever after 4 to 7 days of broad spectrum antibiotics
High risk prolonged neutropenia
Echinocandin option
Micafungin IV
100 mg IV daily
Hepatic monitoring
Azole option when appropriate
Voriconazole IV or PO
Loading and maintenance per local protocol
QT prolongation and drug interactions
Amphotericin option for suspected mucormycosis or refractory infection
Liposomal amphotericin B IV
3 to 5 mg/kg daily typical range
Electrolyte and renal monitoring
Viral reactivation and treatment
HSV coverage when suspected
Acyclovir IV
10 mg/kg IV every 8 hours for severe disease
Renal dose adjustment requirement
Influenza treatment when indicated
Oseltamivir PO
75 mg PO every 12 hours
Renal dose adjustment requirement
Source control and adjuncts
Source directed actions
Central line management
Early infectious diseases input for suspected CLABSI
Removal consideration with persistent bacteremia or tunnel infection
Obstruction management
Urology consult for obstructed infected collecting system
Decompression timing urgency
Typhlitis management
Bowel rest
Surgical consult for perforation or necrosis concern
Hematologic adjuncts
G CSF considerations
Severe sepsis or septic shock
Expected prolonged neutropenia
Pneumonia or invasive fungal infection concern
Transfusion thresholds per oncology service
Symptomatic anemia
Severe thrombocytopenia with bleeding risk
Special Populations
Pregnancy
Pregnancy specific considerations
Maternal first stabilization
Sepsis resuscitation priority
Obstetric consultation early
Antibiotic selection safety
Beta lactams preferred when appropriate
Avoid tetracyclines
Fetal considerations
Fetal monitoring based on gestational age
Preterm labor screening if abdominal pain
Geriatric
Older adult considerations
Atypical presentation risk
Afebrile sepsis with hypothermia
Delirium as primary sign
Renal dosing vigilance
Creatinine clearance estimation pitfalls with low muscle mass
Higher drug toxicity risk
Goals of care
Early discussion when advanced malignancy
ICU appropriateness alignment
Pediatrics
Pediatric febrile neutropenia
Fever and risk thresholds
Institutional pathway reliance common
High risk default for infants and unstable children
Weight based antibiotic dosing examples
Cefepime IV
50 mg/kg per dose IV every 8 hours
Maximum per dose per local protocol
Piperacillin tazobactam IV
80 mg/kg piperacillin component IV every 6 hours
Maximum per dose per local protocol
Disposition tendencies
Admission common for most pediatric oncology patients
Outpatient only with established oncology protocol and reliable follow up
Background
Epidemiology
Frequency and impact
Common oncologic emergency
High hospitalization burden in cancer care
Major driver of chemotherapy dose reductions and delays
Pathogen patterns
Gram negative bacteremia remains high mortality risk
Gram positive infections common with indwelling lines and mucositis
Pathophysiology
Host defense failure model
Neutrophil depletion
Reduced phagocytosis and bacterial killing
Blunted local inflammatory signs
Mucosal barrier injury
Translocation of gut flora
Higher bacteremia risk
Device related inoculation
Biofilm on central lines
Persistent bacteremia risk
Therapeutic Considerations
Time dependent outcomes concept
Early effective antibiotics
Mortality reduction association in septic shock
Delays increase complication risk
De escalation logic
Narrowing based on cultures and clinical stability
Stewardship to reduce resistance and C difficile
Empiric MRSA coverage selectivity
Avoid routine vancomycin without indications
Reduce nephrotoxicity and resistance pressures
Patient Discharge Instructions
Copy discharge instructions
Discharge education and safety net
Antibiotic plan
Take antibiotics exactly as prescribed
Do not skip doses
Temperature monitoring
Check temperature at least twice daily for 48 to 72 hours
Avoid antipyretics to mask fever unless instructed
Return to ED immediately for
Temperature >= 38.0 C
Chills or rigors
Shortness of breath
Chest pain
New confusion
Dizziness or fainting
New rash or rapidly spreading redness
Severe abdominal pain
Persistent vomiting or inability to keep fluids down
Decreased urination
Follow up plan
Oncology or clinic contact within 24 to 48 hours
Blood culture callback plan and contact number
References
Clinical guidelines and evidence sources
Core guideline sources
Infectious Diseases Society of America guideline for fever and neutropenia in cancer patients
Empiric anti pseudomonal beta lactam for high risk febrile neutropenia
Oral outpatient regimens for carefully selected low risk patients
ASCO and IDSA outpatient management guidance for low risk febrile neutropenia
Risk stratification use with MASCC and clinical judgment
Early follow up within 24 to 48 hours
Emergency care and stewardship concepts
Early antibiotics in sepsis bundles
Antibiotic within 60 minutes for suspected sepsis when feasible
Hemodynamic stabilization priority
Gram positive coverage indications
Vancomycin reserved for defined clinical indications rather than routine use
Source file
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.