The target is the first dose of a broad-spectrum antibiotic within an hour of the fever being recorded, and the commonest cause of missing it is waiting for a full blood count to confirm the neutropenia. That sequence is backwards. In a patient within the expected nadir after cytotoxic chemotherapy, a fever is the indication; the count confirms what you already assumed and arrives too late to be part of the decision.
The second commonest cause of delay is triage. A patient who looks well, is walking, and has a temperature of 38.2 does not generate urgency in a busy department, and neutropenic sepsis is notorious for looking unremarkable an hour before it does not.
The operational fix is a card. A patient starting chemotherapy should leave with a written instruction that a fever means presenting immediately and showing the card, and the card should say that antibiotics are given before investigations. The clinical decision is easy; the delay is always in the system around it.
- Give the first antibiotic dose within an hour of the recorded fever, before the blood count returns
- Take blood cultures on the way to the antibiotic, not before it
- Issue a chemotherapy alert card that states the one-hour target explicitly
- Treat a well-looking neutropenic patient with fever as urgent regardless of appearance
- Audit door-to-antibiotic time; it is the number that separates units, not the choice of agent
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