The MASCC (Multinational Association of Supportive Care in Cancer) score identifies low-risk febrile neutropenia (FN) patients who can be treated with oral antibiotics, often as outpatients. Score ≥ 21 (max 26) = low risk; score < 21 = high risk requiring inpatient IV therapy.

Febrile neutropenia is defined as a single oral temp ≥ 38.3°C OR ≥ 38.0°C sustained ≥ 1 h, with ANC < 500/μL (or expected to drop below 500 within 48 h).

Time to first antibiotic is the strongest predictor of FN mortality. ESMO, NCCN, IAP all mandate antibiotic within 60 minutes of fever onset. Indian centres often miss this target — EasyClinic's FN pathway enforces it.

• High-risk: IV piperacillin-tazobactam 4.5 g q6h OR cefepime 2 g q8h OR meropenem 1 g q8h (adult doses; paediatric: 90 mg/kg/day pip-taz divided q6-8h).
• Low-risk: Ciprofloxacin 750 mg PO BD + amoxicillin-clavulanate 875/125 mg PO TID (paediatric: cipro 20 mg/kg BD + amoxiclav 45 mg/kg BD).
• Add vancomycin if: catheter sepsis, hemodynamic instability, severe mucositis, MRSA colonisation, gram-positive blood culture.

The Indian Paediatric Oncology Group (INPOG) and Tata Memorial have published India-specific FN protocols accounting for high prevalence of multi-drug resistant Gram-negatives (ESBL, CRE) and tuberculosis risk:

• First-line is institution-dependent. Many Indian centres start with cefoperazone-sulbactam or piperacillin-tazobactam.
• De-escalation by 48-72 h based on culture sensitivity is critical for stewardship.
• G-CSF (filgrastim 5 μg/kg/day SC, ₹1,200-3,000 per dose; pegfilgrastim ₹15,000-25,000 single dose) per ASCO/IAP criteria — FN with high risk of complications, expected prolonged neutropenia, or as primary prophylaxis for high-FN-risk chemo (> 20%).
• Empirical antifungal (caspofungin, voriconazole, liposomal amphotericin B) if fever persists > 96 h or relapsing.

• Septic shock (hypotension despite 60 mL/kg fluid bolus)
• Respiratory failure requiring > 60% FiO₂ or invasive ventilation
• DIC or organ dysfunction
• ANC < 100 with prolonged fever > 4 days on broad-spectrum antibiotics
• Encephalopathy / altered sensorium