Febrile Neutropenia MASCC Score

Febrile neutropenia (FN) is a common and potentially life-threatening complication of cancer chemotherapy, defined as a single oral temperature above 38.3°C or a temperature above 38.0°C sustained for more than one hour in a patient with an absolute neutrophil count (ANC) below 500 cells/µL or an ANC expected to fall below 500 cells/µL within 48 hours. FN requires immediate medical evaluation because neutropenic patients lack the ability to mount effective immune responses against bacterial and fungal pathogens, placing them at high risk of sepsis and death without prompt antibiotic therapy. Risk stratification at the time of FN presentation is critical for determining whether a patient can be managed with oral antibiotics at home or requires intravenous antibiotics and hospitalisation. The Multinational Association for Supportive Care in Cancer (MASCC) risk index is the most widely validated tool for this purpose. The MASCC score uses seven clinical variables: burden of illness (assessed by severity of FN signs and symptoms, 0–5 points), absence of hypotension (5 points), absence of chronic obstructive pulmonary disease (4 points), solid tumour or lymphoma without prior fungal infection (4 points), absence of dehydration (3 points), outpatient status at onset of fever (3 points), and age below 60 years (2 points). The maximum MASCC score is 26. A score of 21 or above identifies patients as low-risk — defined as those with less than 5% risk of serious medical complications — who may be candidates for oral antibiotic therapy (ciprofloxacin + amoxicillin-clavulanate) and early discharge or outpatient management. Patients with MASCC scores below 21 are classified as high-risk and require hospital admission and intravenous broad-spectrum antibiotics.

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1. 1Assess burden of febrile illness at presentation: 5 points for no/mild symptoms, 3 points for moderate symptoms, 0 points for severe symptoms (the only variable where higher symptoms give lower score).
2. 2Assess blood pressure: assign 5 points if systolic BP is ≥90 mmHg (no hypotension). Hypotension (SBP <90) scores 0 for this component.
3. 3Assess for known chronic obstructive pulmonary disease (COPD) or active pulmonary disease: 4 points if the patient has no COPD or active chronic pulmonary disease.
4. 4Assess tumour type and infection history: 4 points if the patient has a solid tumour or haematological malignancy without a prior fungal infection. Patients with prior documented invasive fungal infection or haematological malignancy with prior fungal disease score 0.
5. 5Assess hydration status: 3 points if no significant dehydration requiring IV fluids. Dehydration requiring IV fluids scores 0.
6. 6Assess onset setting: 3 points if the patient was an outpatient when the fever developed. Inpatient onset of fever scores 0.
7. 7Assess age: 2 points if the patient is younger than 60 years. Age 60 or above scores 0. Sum all components. Score ≥21 = low risk (outpatient antibiotics may be appropriate); score <21 = high risk (hospitalise and administer IV antibiotics).

• !Misscoring the burden of illness component — it is the only variable that is NOT binary; it is a 3-tier (0/3/5) assessment of symptom severity, not a yes/no question.
• !Assuming MASCC ≥21 alone is sufficient to discharge without confirming other discharge eligibility criteria: adequate social support, reliable telephone access, proximity to hospital, patient and caregiver understanding of return precautions.
• !Failing to take blood cultures before administering the first antibiotic dose — cultures must be collected prior to antibiotics to maximise pathogen yield, which guides de-escalation.
• !Using MASCC in haematology patients receiving myeloablative chemotherapy — these patients have prolonged expected neutropenia and should always be admitted regardless of initial MASCC score.
• !Not reassessing MASCC if the patient deteriorates in the first few hours — a patient who was MASCC 21 on arrival and then becomes hypotensive at hour 4 has crossed into high-risk territory requiring escalation.
• !Forgetting to start G-CSF prophylaxis for subsequent cycles after an episode of FN — a history of FN on a particular regimen is the clearest indication for secondary G-CSF prophylaxis in future cycles.