Impact of Manchester Triage on the Referral Pathway of Febrile Neutropenia Patients in the Emergency Department – A Single-Center Experience

Impact of Manchester Triage on the Referral Pathway of Febrile Neutropenia Patients in the Emergency Department – A Single-Center Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Manchester Triage on the Referral Pathway of Febrile Neutropenia Patients in the Emergency Department – A Single-Center Experience Alexandra Guedes, Joana Cabral, Beatriz Belo, Sandra Silva, Patrícia Liu, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7387709/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: Febrile neutropenia is a frequent complication of oncological treatment. Empirical antibiotic therapy should be started within the first hour after admission. Delays in its administration are associated with prolonged hospital stays and higher mortality rates. Our aim was to assess the impact of Manchester Triage of febrile neutropenia patients admitted to the Emergency Department (ED) on time to antibiotic initiation. Methods: Patients with cancer admitted to the ED of our institution in 2022 who had a diagnosis of febrile neutropenia were selected. Non-oncological patients and children were excluded. Results: Out of 38 patients, 34% were assigned an orange code and 11% a white code (referred from outpatient consultation); all patients in these two groups were directed to Internal Medicine (IM). A yellow triage code was assigned to 55% of patients, who were then directed either to IM or General Medicine (GM), without a defined criterion. Among patients triaged to IM (74%), the median time from admission to initiation of antibiotics was 4h27 (min. 1h08, max. 20h32), while for those triaged to GM (26%), the median was 7h46 (min. 3h04, max. 45h20) (p = 0.03, Mann–Whitney U). Conclusion: the data show that delays are significant and worsened when patients are assigned a yellow Manchester Triage code and are not triaged directly to IM. Proper triage of febrile oncological patients in the ED is crucial, and protocols with well-defined criteria should be implemented to ensure timely treatment. Febrile Neutropenia Emergency Medical Tags Emergency Department Manchester Triage Figures Figure 1 Key Messages Most febrile neutropenia patients in the ED did not receive antibiotics within the recommended 60 minutes. Delays in antibiotic administration were more frequent among patients triaged with yellow codes and referred to General Medicine. There was no statistically significant correlation between time to antibiotic initiation and length of hospital stay or mortality. The observed mortality rate was twice as high as reported in the literature. Timely identification and prioritization of febrile oncological patients is essential for early intervention. A dedicated “fast-track” protocol may reduce treatment delays, with potential impact on morbidity and mortality. 1. Background Febrile neutropenia remains one of the most critical and common oncological complications, particularly among patients with hematologic malignancies or solid tumors undergoing chemotherapy treatment. In fact, 10–50% of patients with solid tumors and up to 80% of those with hematologic cancers will develop at least one episode of fever associated with neutropenia during chemotherapy [ 1 ]. It is clinically defined by an oral temperature exceeding 38.3°C, or two consecutive readings above 38.0°C over a two-hour period, in the presence of an absolute neutrophil count (ANC) below 500/µL, or below 1000/µL with an expected decline to < 500/µL within 48 hours [ 1 , 2 ]. In neutropenic patients, while progression to sepsis is rapid, classical signs of infection may be absent or attenuated due to the immunosuppressed state. As such, fever often stands as the only clinical manifestation of an underlying infection [ 3 ]. The severity of infection is inversely correlated with neutrophil count, with ANC < 100/µL being associated with significantly higher rates of bacteremia and more severe outcomes [ 2 ]. Overall, febrile neutropenia carries a substantial burden of morbidity and mortality, with in-hospital mortality rates approaching 10% [ 2 ]. To stratify risk and guide management, the Multinational Association for Supportive Care in Cancer (MASCC) risk index is widely used. It takes into account age, clinical presentation, presence of hypotension and hypovolemia, type of primary tumor, comorbidities, and the context of infection (nosocomial versus outpatient). A MASCC score ≥ 21 indicates a low risk of complications with mortality rates under 5%. On the other hand, patients with a MASCC score < 21 should be considered high risk; mortality rates can reach 40% for scores < 15 [ 4 ]. Thus, patients with a MASCC score < 21 or with clinical severity criteria should be admitted for inpatient care with immediate initiation of broad-spectrum antibiotic therapy. Timely administration of antibiotics is a well-established determinant of outcomes in febrile neutropenia. International guidelines from the Infectious Diseases Society of America (IDSA), the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) recommend initiating empirical antimicrobial therapy within the first hour following triage and evaluation [ 1 , 3 , 4 ]. Delays in antibiotic initiation have been linked to prolonged hospital stays and increased mortality [ 5 , 6 ]. A retrospective cohort study including 307 cases of febrile neutropenia showed that each hour of delay in initiating antibiotics increases 28-day mortality by 18% [ 7 ]. Despite these recommendations, real-world implementation - particularly in emergency settings - remains inconsistent. The Manchester Triage System (MTS) is a widely used tool in Portuguese EDs to prioritize patient care based on clinical urgency. It assigns patients to one of five categories, each represented by a color code indicating the maximum recommended waiting time for medical assessment: red (immediate assessment), orange (very urgent, within 10 minutes), yellow (urgent, within 60 minutes), green (standard, within 120 minutes), and blue (non-urgent, within 240 minutes) [ 8 ]. In many hospitals, these categories are physically signaled by wristbands of corresponding colors, to ensure that healthcare teams can quickly identify priority levels. Although effective for general emergency care, the MTS was not specifically designed for immunocompromised patients, such as those with febrile neutropenia, potentially leading to under-triage and delays in critical treatment. Given the nonspecific or masked clinical presentation of neutropenic patients, combined with the lack of training among triage teams regarding the risks associated with oncological treatments, cancer patients presenting with fever are often assigned a green or yellow triage code and end up being referred to non-specialized teams, leading to significant delays in the initiation of treatment. To date, no national data have been published evaluating how current triage systems affect time to antibiotic administration in febrile neutropenia cases. This study aims to evaluate how triage classification of febrile neutropenia patients admitted to the ED influences the time to first antibiotic administration. Furthermore, it seeks to assess the impact of this timing on hospital length of stay and in-hospital mortality. 2. Methods A retrospective cohort study was conducted including all adult cancer patients admitted to ED of a tertiary hospital - Unidade Local de Saúde Gaia e Espinho, from January to December of 2022, with a final diagnosis of febrile neutropenia. The diagnosis was established according to international guidelines, combining fever (oral temperature > 38.3°C or two consecutive readings > 38.0°C within two hours) with ANC < 500/µL, or < 1000/µL with a projected decrease to < 500/µL within 48 hours. Clinical and demographic data were retrieved through electronic medical records using the ALERT® and SClínico® systems. Variables collected included triage classification, referral team (Internal Medicine or General Medicine), and time from ED admission to the first administration of antibiotics. Statistical analysis was performed using IBM SPSS® v27. In the descriptive analysis, continuous variables were presented as mean and standard deviation if normally distributed, and as medians with minimum and maximum values if not normally distributed; categorical variables were presented as absolute frequencies and percentages. Time to initiation of antibiotic therapy was compared between groups defined by triage category and the corresponding referral team, as well as length of hospital stay and in-hospital mortality. 3. Results A total of 38 patients with febrile neutropenia were included in the study. The cohort had a male predominance, with 55% male and 45% female patients. The mean age was 68.2 years (standard deviation ±9.4). In terms of functional status, most patients had preserved autonomy, with 50% (n=19) classified as ECOG 1, followed by 26,3% (n=10) ECOG 2, 21.1% (n= 8) ECOG 0, and a single patient (2.6%) with ECOG 3 (table 1). Regarding tumor types, 58% (n=22) had solid tumors, with lung cancer being the most common (21.1%), followed by breast cancer (10.5%). Other primary tumor sites included head and neck, colorectal, pancreas, ovary, leiomyosarcoma, and bladder. The remaining 42% (n=16) of patients had hematological malignancies, with non-Hodgkin lymphoma (NHL) (23.7%) being the most represented. Other hematological cancers included acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM) (table 1). Among patients with hematological malignancies, neutropenia was attributed to the disease itself in four patients (two AML, one NHL and one MM with bone marrow infiltration), while the remaining patients were neutropenic as a result of chemotherapy’s hematological toxicity. The most frequently used chemotherapy regimens among patients with solid tumors were platinum-based doublets (26.3%, n=10). Among patients with hematologic malignancies, the most common regimen was R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone) (18%, n=7). The interval between the last chemotherapy session and the ED admission was 8.9 days (SD 4.4), which corresponds with the expected nadir period for most cases of chemotherapy-induced neutropenia (table 1). Based on the MASCC risk index, 68% of patients (n=26) had a score ≥21, indicating low risk, while 32% (n=12) were classified as high-risk with scores <21. All patients presented with ANC <500 cells/µL at the time of the febrile episode, with half (50%) having severe neutropenia (≤100 cells/µL). The most frequent site of infection was the respiratory tract (40%, n=15), followed by gastrointestinal (18%, n=7) and genitourinary tract (10%, n=4). In 32% of patients (n=12), no infectious focus could be identified (table 1). Upon arrival at the ED, the mean time to nurse triage was 7 minutes and 37 seconds (SD 3.77). Fever was the main complaint in over 85% of patients and 68% presented within 24 hours of symptom onset. In 55% of cases, the triage nurse explicitly documented the patient’s ongoing oncological treatment in the notes, indicating general awareness of the relevance of chemotherapy, despite the absence of a standardized mechanism within the triage workflow to flag this clinical context to the ER team. Patients were assigned different triage codes under the Manchester Triage System (table 2): 55% (n=21) received a yellow code, of which 42% (n=10) were directed to General Medicine (GM) and 58% (n=11) to Internal Medicine (IM) or other medical specialties according to the primary tumor; 34% (n=13) were triaged with an orange code, all of whom were referred to IM; 11% (n=4) were issued a white code, typically used for outpatient referrals following an ambulatory hospital visit. These patients presented with a formal referral letter, which resulted in their direct routing to IM. Of these, three already had hemogram results (and thus the diagnosis of febrile neutropenia confirmed) and two had already started antibiotic therapy. Among yellow coded patients, 19% were high-risk (MASCC <21), compared to 54% of those with an orange code (table 2). Patients triaged to IM had a median time from admission to hemogram result of 1 hour and 30 minutes (IQR 1.46 h), compared to 2 hours and 45 minutes (IQR 3.83 h) for those triaged to GM. The maximum wait times were 6 hours 30 minutes and 8 hours 36 minutes, respectively. There was no statistical significance between both groups (p = 0.46, Mann–Whitney U) (table 3). The median time from admission to antibiotic initiation was 4 hours and 27 minutes (min. 1h08, max. 20h32) for patients referred to IM, while it was considerably longer - 7 hours and 46 minutes (min. 3h04, max. 45h20) - for those referred to GM. This difference was statistically significant (p = 0.03, Mann–Whitney U) (table 3). A total of 74% (n=28) of patients required hospitalization, while 26% (n=10) were managed in the outpatient setting. All 12 patients with a MASCC score of less than 21 were hospitalized. Among those admitted, 64% were hospitalized within the first 24 hours; the remaining 36% were admitted between the second and the fifth day, with delays primarily attributed to the unavailability of inpatient beds. The most frequently prescribed antibiotic regimen was piperacillin-tazobactam, used in 50% of cases. Other regimens included third-generation cephalosporins with ciprofloxacin (13%), vancomycin (5%) and meropenem (3%); antifungal treatment was given in two patients (5%). Adjustments to the initial antibiotic regimen were required in several cases: 5% and 8% of patients required broadening or narrowing of antibiotic spectrum, respectively, and 8% were switched to targeted therapy after antibiotic susceptibility testing results. The median duration of hospital stay was 8.5 days (IQR 4.75), with a maximum of 50 days. No statistically significant correlation was observed between the time to antibiotic initiation and the length of hospitalization (p = 0.878, Spearman correlation). The in-hospital mortality rate was 21% (n=8). The mean time to death was 4.38 days (SD 3.38), with a maximum of 11 days. Among patients with a MASCC score <21, the mortality rate was 42%, whereas it was 12% for those with a score ≥21. A significant association was found between MASCC score and mortality (p = 0.034, Chi-squared test). No significant association was found between time to antibiotic initiation and mortality (p = 0.82, Mann-Whitney U). Among the 30 survivors, three were re-admitted due to need for antibiotic adjustment and inpatient care. Six required re-hospitalization, including: two due to escalation of antimicrobial therapy; four for unrelated medical reasons, one of whom later died from disease progression. The 30-day mortality rate was 24% (n=9). 4. Discussion This study highlights important shortcomings in the emergency triage and initial management of patients with febrile neutropenia within a real-world hospital setting. While limited by its small sample size and single-center scope, several key findings merit reflection. Firstly, the study cohort is likely under-representative of the most severe febrile neutropenia cases. Patients with more advanced clinical deterioration or sepsis may have been coded under alternative diagnoses and thus were excluded from analysis. Additionally, many low-risk patients with solid tumors (particularly those with MASCC scores ≥ 21) were managed at the Oncological Day Hospital and did not require ED evaluation. This department, which operates only during weekday mornings and early afternoon, provides scheduled and unscheduled care including blood draws and intravenous antibiotic administration. In these situations, if there is need for inpatient treatment, the patient is usually directed to the ED along with a letter of referral, which leads to them receiving a white code and to be directed to IM. In our sample, 2 out of 4 patients referred from outpatient clinics lacked formal hemogram results or had pre-initiated antibiotic therapy. A standardized protocol requiring patients to arrive at the ED with a written referral addressed to Internal Medicine and with laboratory testing and antibiotics already initiated could streamline care and reduce avoidable delays. Notably, in our sample, all patients with solid tumors who independently accessed the ED did so during weekends, holidays, or after 2 p.m., periods during which the Day Hospital was unavailable. It was not possible to know the real time from triage to medical observation, since medical records are often written later. Nonetheless, significant delays were observed in the time from admission to key clinical milestones, reflecting a clear deviation from international recommendations. Guidelines advocate initiating empirical antibiotic therapy within the first hour of presentation [ 1 , 3 , 4 ]. However, this benchmark was not met in our sample. The median time to antibiotic initiation ranged from 4.5 to nearly 8 hours, depending on triage category and referral pathway. Patients triaged with a yellow code, who accounted for more than half of the sample, experienced the longest delays, particularly when referred to General Medicine. In these patients, time to antibiotic administration was nearly twice as long as in those triaged to Internal Medicine. This discrepancy can be partly explained by systemic organizational factors. Within our institution, the General Medicine team is typically responsible for managing patients triaged as lower-priority (green or yellow codes) and operates under significantly more constrained resources, with a high patient-to-physician ratio and broader clinical responsibilities, which may delay the timely assessment and treatment of high-risk individuals inadvertently triaged to their care. Although the MASCC score was significantly associated with in-hospital mortality in our sample (p < 0.05), it does not fully account for the elevated mortality rate observed (21%), which is more than double the ~ 10% typically reported in the literature [ 2 ]. Notably, even when analysing mortality rates within each MASCC category (scores < 21 and ≥ 21), we found rates higher than those generally expected for both risk groups [ 4 ]. One plausible contributing factor to this elevated mortality is triage misclassification. Patients with febrile neutropenia who were not promptly identified as high-risk may have experienced significant delays in diagnostic work-up (e.g., hemogram) and initiation of empirical antibiotic therapy, both of which are time-sensitive interventions. As such, while the MASCC index remains a valuable prognostic tool, its predictive power may be limited in real-world settings where organizational and procedural factors - such as triage delays - play a critical role. On the other hand, contrary to international evidence demonstrating a strong association between delayed antibiotic initiation and adverse outcomes, including increased mortality and longer hospital stays, our analysis did not identify a statistically significant correlation between time to antibiotics and either mortality or length of hospitalization [ 5 – 7 ]. This apparent discrepancy may be explained by several limitations. The relatively small sample size may have reduced the statistical power needed to detect associations. In addition, the study did not control for potentially important confounding variables such as comorbidities (e.g., cardiovascular disease, diabetes), causative pathogens, multidrug resistance, or the presence of bacteremia - all of which could independently influence clinical outcomes. Future research with larger sample sizes and more comprehensive data collection is warranted to clarify these associations and identify which specific clinical and systemic factors most influence outcomes in this vulnerable population. 5. Conclusion This study reveals critical gaps between established guidelines and real-world practice in the management of febrile neutropenia in the ED. The majority of patients failed to receive empirical antibiotic therapy within the recommended first hour after admission, with delays significantly more pronounced in those who received a yellow code and were triaged to General Medicine rather than Internal Medicine. Given the high-risk nature of febrile neutropenia and its associated morbidity and mortality, it is imperative that all oncological patients presenting with fever are systematically referred to Internal Medicine, bypassing generalist pathways that may lead to treatment delays. These findings support the implementation of a dedicated internal “fast-track” protocol for oncological patients with fever. Such a pathway should include (Fig. 1 ): Immediate electronic identification of oncological status at the moment of patient triage and fast-track protocol initiated; Automatic assignment of an orange code (high-priority); Direct referral to Internal Medicine or other appropriate specialties; Hemogram and blood cultures obtained within 10 minutes; Initiation of empirical antibiotic therapy within 60 minutes; Ideally administered after hemogram confirmation, but not delayed beyond 60 minutes if results are unavailable; Standardized regimens based on hemodynamic stability (e.g., piperacillin-tazobactam if hemodynamically unstable or ceftriaxone if not); Early clinical reassessment to determine outpatient versus inpatient management and adjust treatment. Adopting such a protocol would help ensure timely, guideline-adherent care and may reduce preventable delays, morbidity, and mortality in this vulnerable population. Translating theoretical recommendations into clinical practice is essential to improving outcomes for febrile neutropenia patients. We recommend that this analysis be repeated following the implementation of the fast-track protocol, to assess its impact on key clinical metrics such as time to antibiotic initiation and adherence to international benchmarks, hospitalization duration, and mortality. Ideally, this should be conducted as a multi-center study to enhance the generalizability of findings and support broader implementation across healthcare institutions. Finally, given the rising incidence of cancer worldwide and projections indicating that it may soon become the leading cause of mortality in developed countries [ 9 ], it is crucial to recognize febrile neutropenia as a frequent and potentially life-threatening complication of oncological treatment. Just as dedicated fast-track pathways exist for conditions such as stroke or myocardial infarction, the implementation of an equally robust protocol for febrile neutropenia is imperative to ensure timely, effective care for this growing patient population. Key Messages : Most febrile neutropenia patients in the ED did not receive antibiotics within the recommended 60 minutes. Delays in antibiotic administration were more frequent among patients triaged with yellow codes and referred to General Medicine. There was no statistically significant correlation between time to antibiotic initiation and length of hospital stay or mortality. The observed mortality rate was twice as high as reported in the literature. Timely identification and prioritization of febrile oncological patients is essential for early intervention. A dedicated “fast-track” protocol may reduce treatment delays, with potential impact on morbidity and mortality. Statements & Declarations Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Authors contribution All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Alexandra Guedes, Joana Cabral, Beatriz Belo, Sandra Silva, Patrícia Liu, Raquel Basto, Joana Marinho, Raquel Monteiro, Adriana Soares, Maria Castelo Branco, Cristiana Marques, Ana Barroso, Henrique Coelho, José Ribeiro Almeida, Enrique Dias, A. Moreira Pinto, Sandra Custódio, and Andreia Capela. The first draft of the manuscript was written by Alexandra Guedes and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethical Considerations This is a retrospective observational study approved by the institutional ethics committee of the Gaia/Espinho Local Health Unit (Comissão de Ética da ULS Gaia/Espinho). The need for informed consent was waived due to the retrospective nature of the study and the use of anonymized patient data. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Data availability No additional data is available. Code availability Not applicable. References Klastersky J, Paesmans M, Rubenstein EB, Boyer M, Elting L, Feld R, et al. The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol. 2000;18(16):3038–51. https://doi.org/10.1200/JCO.2000.18.16.3038 Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56–93. https://doi.org/10.1093/cid/cir073 Klastersky J, de Naurois J, Rolston K, Rapoport B, Maschmeyer G, Aapro M, et al. Management of febrile neutropaenia: ESMO clinical practice guidelines. Ann Oncol. 2016;27(Suppl 5):v111–8. https://doi.org/10.1093/annonc/mdw325 Flowers CR, Seidenfeld J, Bow EJ, Karten C, Gleason C, Hawley DK, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2013;31(6):794–810. https://doi.org/10.1200/JCO.2012.45.8661 Tam CS, O’Reilly M, Andresen D, Fong A, Worth LJ, Slavin MA. Use of empiric antimicrobial therapy in neutropenic fever. Intern Med J. 2011;41 Suppl 1:90–101. https://doi.org/10.1111/j.1445-5994.2010.02340.x Perron T, Emara M, Ahmed N, Marzouk K, Downey D, Siemens DR. Time to antibiotics and outcomes in cancer patients with febrile neutropenia. BMC Health Serv Res. 2014;14:162. https://doi.org/10.1186/1472-6963-14-162 Rosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother. 2014;58(7):3799–803. https://doi.org/10.1128/AAC.02561-14 Manchester Triage Group. Emergency Triage. 3rd ed. London: BMJ Publishing Group; 2014. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49. https://doi.org/10.3322/caac.21660 Tables Table 1 – Demographic and clinical characteristics of febrile neutropenia patients admitted to the ED (n=38). Age, mean (SD) 68.2 (±9.4) Sex , n (%) Male Female 21 (55.3) 17 (44.7) ECOG performance status , n (%) 0 1 2 3 8 (21.1) 19 (50) 10 (26.3) 1 (2.6) Primary tumor type , n (%) Solid Tumors Lung Breast Head and Neck Colorrectal Pancreatic Ovarian Leiomyosarcoma Bladder Hematologic malignancies Non-Hodgkin lymphoma Acute myeloid leukemia Mielodysplastic syndrome Chronic lymphocytic leukemia Multiple myeloma 22 (57.9) 8 (21.1) 4 (10.5) 3 (7.9) 3 (7.9) 1 (2.6) 1 (2.6) 1 (2.6) 1 (2.6) 16 (42.1) 9 (23.7) 3 (7.9) 2 (5.3) 1 (2.6) 1 (2.6) Neutropenia cause Disease-related Chemotherapy-related 4 (10.5) 34 (89.5) Chemotherapy regimens Solid tumors Platinum doublet Taxane monotherapy Topotecan monotherapy Others Hematologic malignancies R-CHOP Azacytidine Others 8 (21.1) 2 (5.3) 2 (5.3) 10 (26.3) 7 (18.4) 2 (5.3) 7 (18.4) Time since last chemotherapy, mean (SD) 8.9 (±4.4) days ANC at admission , n (%) <500 cells/µL ≤100 cells/µL 38 (100) 19 (50) MASCC risk score , n (%) ≥21 (low risk) <21 (high risk) 26 (68.4) 12 (31.6) Infection site, n (%) Respiratory tract Gastrointestinal tract Genitourinary tract No identified focus 15 (40) 7 (18.4) 4 (10.5) 12 (31.6) Table 2 – Triage and orientation of febrile neutropenia patients admitted to the ED (n=38). Triage Code Orientation, n (%) MASCC score, n (%) Total, n (%) Internal Medicine / Specialties General Medicine <21 ≥ 21 O range 13 (100) 0 7 (54) 6 (46) 13 (34) Yellow 11 (58) 10 (42) 4 (19) 17 (81) 21 (55) White 4 (100) 0 1 (25) 3 (75) 4 (11) Total , n (%) 28 (74) 10 (26) 12 (32) 26 (68) 38 (100) Table 3 – Clinical outcomes of febrile neutropenia patients admitted to the ED (n = 38). Internal Medicine General Medicine Mann–Whitney U Time from admission to hemogram, median (min; max) 1h30 (0h42; 6h30) 2h45 (0h30; 8h36) p = 0.46* Time from admission to antibiotics, median (min; max) 4h27 (1h08; 20h32) 7h46 (3h04; 45h20) p = 0.03 * Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 30 Oct, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviewers agreed at journal 03 Oct, 2025 Reviewers invited by journal 01 Oct, 2025 Editor assigned by journal 01 Oct, 2025 Submission checks completed at journal 22 Aug, 2025 First submitted to journal 16 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7387709","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528166917,"identity":"359ae91b-3d13-4585-81ab-4716148ed17b","order_by":0,"name":"Alexandra 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Cabral","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Joana","middleName":"","lastName":"Cabral","suffix":""},{"id":528166920,"identity":"e528134a-071b-4022-933b-065883f40f3d","order_by":2,"name":"Beatriz Belo","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Beatriz","middleName":"","lastName":"Belo","suffix":""},{"id":528166921,"identity":"a2236594-9cf1-4f09-b18e-aa98d7ae6665","order_by":3,"name":"Sandra Silva","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Silva","suffix":""},{"id":528166923,"identity":"2647b014-b2de-4ca6-9092-20939da59ee0","order_by":4,"name":"Patrícia Liu","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Patrícia","middleName":"","lastName":"Liu","suffix":""},{"id":528166927,"identity":"c6a82bd7-1889-45c4-8348-0df3dd6d84e0","order_by":5,"name":"Raquel Basto","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Raquel","middleName":"","lastName":"Basto","suffix":""},{"id":528166929,"identity":"563f274d-d857-4901-ab1e-543503bbec42","order_by":6,"name":"Joana Marinho","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Joana","middleName":"","lastName":"Marinho","suffix":""},{"id":528166933,"identity":"ccd3cc7c-f6a5-4cf2-8ada-97021390be8b","order_by":7,"name":"Raquel Monteiro","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Raquel","middleName":"","lastName":"Monteiro","suffix":""},{"id":528166934,"identity":"d6703450-bc91-4c78-89d4-e69a8b0204e4","order_by":8,"name":"Adriana Soares","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"","lastName":"Soares","suffix":""},{"id":528166935,"identity":"212fd651-4d02-4e52-9604-a003a0280b4a","order_by":9,"name":"Maria Castelo Branco","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Castelo","lastName":"Branco","suffix":""},{"id":528166937,"identity":"951a06e0-f388-49a8-a0d6-c5377a722da4","order_by":10,"name":"Cristiana Marques","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Cristiana","middleName":"","lastName":"Marques","suffix":""},{"id":528166940,"identity":"d4e20e22-d07c-47ec-9699-69115ac57ab8","order_by":11,"name":"Ana Barroso","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Barroso","suffix":""},{"id":528166941,"identity":"3c5945b3-69ce-4fe5-9c63-78b71d24f3b5","order_by":12,"name":"Henrique Coelho","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Henrique","middleName":"","lastName":"Coelho","suffix":""},{"id":528166942,"identity":"2e63f975-1af2-4bce-b995-73b13588254a","order_by":13,"name":"José Ribeiro Almeida","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Ribeiro","lastName":"Almeida","suffix":""},{"id":528166943,"identity":"85cfa565-c538-4b2d-aacc-0a118bb168dd","order_by":14,"name":"Enrique Dias","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Enrique","middleName":"","lastName":"Dias","suffix":""},{"id":528166944,"identity":"386403c7-808d-41d2-8b1f-9619ebf66f78","order_by":15,"name":"A. Moreira Pinto","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"A.","middleName":"Moreira","lastName":"Pinto","suffix":""},{"id":528166945,"identity":"15a1606e-d789-489a-97fc-f327b8a32d6b","order_by":16,"name":"Sandra Custódio","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Custódio","suffix":""},{"id":528166946,"identity":"6f4baaec-146e-4518-a848-50db4f2a6489","order_by":17,"name":"Andreia Capela","email":"","orcid":"","institution":"Gaia/Espinho Local Health Unit","correspondingAuthor":false,"prefix":"","firstName":"Andreia","middleName":"","lastName":"Capela","suffix":""}],"badges":[],"createdAt":"2025-08-16 13:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7387709/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7387709/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-026-10400-y","type":"published","date":"2026-02-03T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93575139,"identity":"25e1f667-5495-4d4b-836e-1d37e5949e12","added_by":"auto","created_at":"2025-10-15 09:22:19","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":144112,"visible":true,"origin":"","legend":"","description":"","filename":"FebrileNeutropeniaArticle.docx","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/604b493d8c86a71d896e0350.docx"},{"id":93574029,"identity":"fa5f8e4b-ccbf-45fd-90c8-b39534b20942","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16782,"visible":true,"origin":"","legend":"","description":"","filename":"9512c853d1b14b98906e0ea8673ac61b.json","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/817a4cc0f2a6d4715449fb6b.json"},{"id":93575138,"identity":"2ba5738f-9abf-47f0-8e71-d7375928b45d","added_by":"auto","created_at":"2025-10-15 09:22:19","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66304,"visible":true,"origin":"","legend":"","description":"","filename":"9512c853d1b14b98906e0ea8673ac61b1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/4e9a0b9b8f32c7e3211549da.xml"},{"id":93575137,"identity":"152e119f-add9-4411-9c0b-715e29dbf7ef","added_by":"auto","created_at":"2025-10-15 09:22:19","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/1b01dab78a6fff78cb818ca0.jpeg"},{"id":93574032,"identity":"fef5120b-3cff-43d2-9fd4-65c619fc2906","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91952,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/9ec443bf1ccad766f80bcc43.png"},{"id":93574033,"identity":"bf233d12-61b1-4075-8183-504df5737944","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/35b6184872bde1f3e002b819.png"},{"id":93574036,"identity":"7e294c11-238d-4000-91da-a0a24a210d90","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65844,"visible":true,"origin":"","legend":"","description":"","filename":"9512c853d1b14b98906e0ea8673ac61b1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/d50daf7576f75822d8f360d4.xml"},{"id":93574037,"identity":"2e686fcd-fd30-4d9c-b680-25af810fdb2a","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75378,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/db5e552bc26078835633786c.html"},{"id":93574030,"identity":"f0601864-83f6-46d8-9bde-a470aabb881e","added_by":"auto","created_at":"2025-10-15 09:14:19","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":472851,"visible":true,"origin":"","legend":"\u003cp\u003eSuggested fast-track protocol for febrile oncological patients in the ED.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eANC: \u003c/em\u003eabsolute neutrophil count; \u003cem\u003eATB: antibiotics; HD: hemodynamically.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/51f34e5d6c8b438f6cb77cb8.jpeg"},{"id":102234009,"identity":"5983dbc2-7061-4b5d-8f30-3300dc41639d","added_by":"auto","created_at":"2026-02-09 16:03:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1321827,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7387709/v1/806d0e48-ef48-4062-b167-56aea581fc3f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Manchester Triage on the Referral Pathway of Febrile Neutropenia Patients in the Emergency Department – A Single-Center Experience","fulltext":[{"header":"Key Messages","content":"\u003cul\u003e\n \u003cli\u003eMost febrile neutropenia patients in the ED did not receive antibiotics within the recommended 60 minutes.\u003c/li\u003e\n \u003cli\u003eDelays in antibiotic administration were more frequent among patients triaged with yellow codes and referred to General Medicine.\u003c/li\u003e\n \u003cli\u003eThere was no statistically significant correlation between time to antibiotic initiation and length of hospital stay or mortality.\u003c/li\u003e\n \u003cli\u003eThe observed mortality rate was twice as high as reported in the literature.\u003c/li\u003e\n \u003cli\u003eTimely identification and prioritization of febrile oncological patients is essential for early intervention. A dedicated \u0026ldquo;fast-track\u0026rdquo; protocol may reduce treatment delays, with potential impact on morbidity and mortality.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Background","content":"\u003cp\u003eFebrile neutropenia remains one of the most critical and common oncological complications, particularly among patients with hematologic malignancies or solid tumors undergoing chemotherapy treatment. In fact, 10\u0026ndash;50% of patients with solid tumors and up to 80% of those with hematologic cancers will develop at least one episode of fever associated with neutropenia during chemotherapy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is clinically defined by an oral temperature exceeding 38.3\u0026deg;C, or two consecutive readings above 38.0\u0026deg;C over a two-hour period, in the presence of an absolute neutrophil count (ANC) below 500/\u0026micro;L, or below 1000/\u0026micro;L with an expected decline to \u0026lt;\u0026thinsp;500/\u0026micro;L within 48 hours [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn neutropenic patients, while progression to sepsis is rapid, classical signs of infection may be absent or attenuated due to the immunosuppressed state. As such, fever often stands as the only clinical manifestation of an underlying infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe severity of infection is inversely correlated with neutrophil count, with ANC\u0026thinsp;\u0026lt;\u0026thinsp;100/\u0026micro;L being associated with significantly higher rates of bacteremia and more severe outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Overall, febrile neutropenia carries a substantial burden of morbidity and mortality, with in-hospital mortality rates approaching 10% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo stratify risk and guide management, the Multinational Association for Supportive Care in Cancer (MASCC) risk index is widely used. It takes into account age, clinical presentation, presence of hypotension and hypovolemia, type of primary tumor, comorbidities, and the context of infection (nosocomial versus outpatient). A MASCC score\u0026thinsp;\u0026ge;\u0026thinsp;21 indicates a low risk of complications with mortality rates under 5%. On the other hand, patients with a MASCC score\u0026thinsp;\u0026lt;\u0026thinsp;21 should be considered high risk; mortality rates can reach 40% for scores\u0026thinsp;\u0026lt;\u0026thinsp;15 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thus, patients with a MASCC score\u0026thinsp;\u0026lt;\u0026thinsp;21 or with clinical severity criteria should be admitted for inpatient care with immediate initiation of broad-spectrum antibiotic therapy.\u003c/p\u003e\u003cp\u003eTimely administration of antibiotics is a well-established determinant of outcomes in febrile neutropenia. International guidelines from the Infectious Diseases Society of America (IDSA), the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) recommend initiating empirical antimicrobial therapy within the first hour following triage and evaluation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Delays in antibiotic initiation have been linked to prolonged hospital stays and increased mortality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A retrospective cohort study including 307 cases of febrile neutropenia showed that each hour of delay in initiating antibiotics increases 28-day mortality by 18% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these recommendations, real-world implementation - particularly in emergency settings - remains inconsistent. The Manchester Triage System (MTS) is a widely used tool in Portuguese EDs to prioritize patient care based on clinical urgency. It assigns patients to one of five categories, each represented by a color code indicating the maximum recommended waiting time for medical assessment: red (immediate assessment), orange (very urgent, within 10 minutes), yellow (urgent, within 60 minutes), green (standard, within 120 minutes), and blue (non-urgent, within 240 minutes) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In many hospitals, these categories are physically signaled by wristbands of corresponding colors, to ensure that healthcare teams can quickly identify priority levels. Although effective for general emergency care, the MTS was not specifically designed for immunocompromised patients, such as those with febrile neutropenia, potentially leading to under-triage and delays in critical treatment. Given the nonspecific or masked clinical presentation of neutropenic patients, combined with the lack of training among triage teams regarding the risks associated with oncological treatments, cancer patients presenting with fever are often assigned a green or yellow triage code and end up being referred to non-specialized teams, leading to significant delays in the initiation of treatment.\u003c/p\u003e\u003cp\u003eTo date, no national data have been published evaluating how current triage systems affect time to antibiotic administration in febrile neutropenia cases.\u003c/p\u003e\u003cp\u003eThis study aims to evaluate how triage classification of febrile neutropenia patients admitted to the ED influences the time to first antibiotic administration. Furthermore, it seeks to assess the impact of this timing on hospital length of stay and in-hospital mortality.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e A retrospective cohort study was conducted including all adult cancer patients admitted to ED of a tertiary hospital - Unidade Local de Sa\u0026uacute;de Gaia e Espinho, from January to December of 2022, with a final diagnosis of febrile neutropenia. The diagnosis was established according to international guidelines, combining fever (oral temperature\u0026thinsp;\u0026gt;\u0026thinsp;38.3\u0026deg;C or two consecutive readings\u0026thinsp;\u0026gt;\u0026thinsp;38.0\u0026deg;C within two hours) with ANC\u0026thinsp;\u0026lt;\u0026thinsp;500/\u0026micro;L, or \u0026lt;\u0026thinsp;1000/\u0026micro;L with a projected decrease to \u0026lt;\u0026thinsp;500/\u0026micro;L within 48 hours.\u003c/p\u003e\u003cp\u003eClinical and demographic data were retrieved through electronic medical records using the ALERT\u0026reg; and SCl\u0026iacute;nico\u0026reg; systems. Variables collected included triage classification, referral team (Internal Medicine or General Medicine), and time from ED admission to the first administration of antibiotics.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using IBM SPSS\u0026reg; v27. In the descriptive analysis, continuous variables were presented as mean and standard deviation if normally distributed, and as medians with minimum and maximum values if not normally distributed; categorical variables were presented as absolute frequencies and percentages. Time to initiation of antibiotic therapy was compared between groups defined by triage category and the corresponding referral team, as well as length of hospital stay and in-hospital mortality.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 38 patients with febrile neutropenia were included in the study. The cohort had a male predominance, with 55% male and 45% female patients. The mean age was 68.2 years (standard deviation \u0026plusmn;9.4). In terms of functional status, most patients had preserved autonomy, with 50% (n=19) classified as ECOG 1, followed by 26,3% (n=10) ECOG 2, 21.1% (n= 8) ECOG 0, and a single patient (2.6%) with ECOG 3 (table 1).\u003c/p\u003e\n\u003cp\u003eRegarding tumor types, 58% (n=22) had solid tumors, with lung cancer being the most common (21.1%), followed by breast cancer (10.5%). Other primary tumor sites included head and neck, colorectal, pancreas, ovary, leiomyosarcoma, and bladder. The remaining 42% (n=16) of patients had hematological malignancies, with non-Hodgkin lymphoma (NHL) (23.7%) being the most represented. Other hematological cancers included acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM) (table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong patients with hematological malignancies, neutropenia was attributed to the disease itself in four patients (two AML, one NHL and one MM with bone marrow infiltration), while the remaining patients were neutropenic as a result of chemotherapy\u0026rsquo;s hematological toxicity.\u003c/p\u003e\n\u003cp\u003eThe most frequently used chemotherapy regimens among patients with solid tumors were platinum-based doublets (26.3%, n=10). Among patients with hematologic malignancies, the most common regimen was R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone) (18%, n=7). The interval between the last chemotherapy session and the ED admission was 8.9 days (SD 4.4), which corresponds with the expected nadir period for most cases of chemotherapy-induced neutropenia (table 1).\u003c/p\u003e\n\u003cp\u003eBased on the MASCC risk index, 68% of patients (n=26) had a score \u0026ge;21, indicating low risk, while 32% (n=12) were classified as high-risk with scores \u0026lt;21. All patients presented with ANC \u0026lt;500 cells/\u0026micro;L at the time of the febrile episode, with half (50%) having severe neutropenia (\u0026le;100 cells/\u0026micro;L). The most frequent site of infection was the respiratory tract (40%, n=15), followed by gastrointestinal (18%, n=7) and genitourinary tract (10%, n=4). In 32% of patients (n=12), no infectious focus could be identified (table 1).\u003c/p\u003e\n\u003cp\u003eUpon arrival at the ED, the mean time to nurse triage was 7 minutes and 37 seconds (SD 3.77). Fever was the main complaint in over 85% of patients and 68% presented within 24 hours of symptom onset. In 55% of cases, the triage nurse explicitly documented the patient\u0026rsquo;s ongoing oncological treatment in the notes, indicating general awareness of the relevance of chemotherapy, despite the absence of a standardized mechanism within the triage workflow to flag this clinical context to the ER team.\u003c/p\u003e\n\u003cp\u003ePatients were assigned different triage codes under the Manchester Triage System (table 2):\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e55% (n=21) received a yellow code, of which 42% (n=10) were directed to General Medicine (GM) and 58% (n=11) to Internal Medicine (IM) or other medical specialties according to the primary tumor;\u003c/li\u003e\n \u003cli\u003e34% (n=13) were triaged with an orange code, all of whom were referred to IM;\u003c/li\u003e\n \u003cli\u003e11% (n=4) were issued a white code, typically used for outpatient referrals following an ambulatory hospital visit. These patients presented with a formal referral letter, which resulted in their direct routing to IM. Of these, three already had hemogram results (and thus the diagnosis of febrile neutropenia confirmed) and two had already started antibiotic therapy.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAmong yellow coded patients, 19% were high-risk (MASCC \u0026lt;21), compared to 54% of those with an orange code (table 2).\u003c/p\u003e\n\u003cp\u003ePatients triaged to IM had a median time from admission to hemogram result of 1 hour and 30 minutes (IQR 1.46 h), compared to 2 hours and 45 minutes (IQR 3.83 h) for those triaged to GM. The maximum wait times were 6 hours 30 minutes and 8 hours 36 minutes, respectively. There was no statistical significance between both groups (p = 0.46, Mann\u0026ndash;Whitney U)\u0026nbsp;(table 3).\u003c/p\u003e\n\u003cp\u003eThe median time from admission to antibiotic initiation was 4 hours and 27 minutes (min. 1h08, max. 20h32) for patients referred to IM, while it was considerably longer - 7 hours and 46 minutes (min. 3h04, max. 45h20) - for those referred to GM. This difference was statistically significant (p = 0.03, Mann\u0026ndash;Whitney U) (table 3).\u003c/p\u003e\n\u003cp\u003eA total of 74% (n=28) of patients required hospitalization, while 26% (n=10) were managed in the outpatient setting. All 12 patients with a MASCC score of less than 21 were hospitalized. Among those admitted, 64% were hospitalized within the first 24 hours; the remaining 36% were admitted between the second and the fifth day, with delays primarily attributed to the unavailability of inpatient beds.\u003c/p\u003e\n\u003cp\u003eThe most frequently prescribed antibiotic regimen was piperacillin-tazobactam, used in 50% of cases. Other regimens included third-generation cephalosporins with ciprofloxacin (13%), vancomycin (5%) and meropenem (3%); antifungal treatment was given in two patients (5%). Adjustments to the initial antibiotic regimen were required in several cases: 5% and 8% of patients required broadening or narrowing of antibiotic spectrum, respectively, and 8% were switched to targeted therapy after antibiotic susceptibility testing results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median duration of hospital stay was 8.5 days (IQR 4.75), with a maximum of 50 days. No statistically significant correlation was observed between the time to antibiotic initiation and the length of hospitalization (p = 0.878, Spearman correlation).\u003c/p\u003e\n\u003cp\u003eThe in-hospital mortality rate was 21% (n=8). The mean time to death was 4.38 days (SD 3.38), with a maximum of 11 days. Among patients with a MASCC score \u0026lt;21, the mortality rate was 42%, whereas it was 12% for those with a score \u0026ge;21. A significant association was found between MASCC score and mortality (p = 0.034, Chi-squared test). No significant association was found between time to antibiotic initiation and mortality (p = 0.82, Mann-Whitney U).\u003c/p\u003e\n\u003cp\u003eAmong the 30 survivors, three were re-admitted due to need for antibiotic adjustment and inpatient care. Six required re-hospitalization, including:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003etwo due to escalation of antimicrobial therapy;\u003c/li\u003e\n \u003cli\u003efour for unrelated medical reasons, one of whom later died from disease progression.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe 30-day mortality rate was 24% (n=9).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study highlights important shortcomings in the emergency triage and initial management of patients with febrile neutropenia within a real-world hospital setting. While limited by its small sample size and single-center scope, several key findings merit reflection.\u003c/p\u003e\u003cp\u003eFirstly, the study cohort is likely under-representative of the most severe febrile neutropenia cases. Patients with more advanced clinical deterioration or sepsis may have been coded under alternative diagnoses and thus were excluded from analysis. Additionally, many low-risk patients with solid tumors (particularly those with MASCC scores\u0026thinsp;\u0026ge;\u0026thinsp;21) were managed at the Oncological Day Hospital and did not require ED evaluation. This department, which operates only during weekday mornings and early afternoon, provides scheduled and unscheduled care including blood draws and intravenous antibiotic administration. In these situations, if there is need for inpatient treatment, the patient is usually directed to the ED along with a letter of referral, which leads to them receiving a white code and to be directed to IM. In our sample, 2 out of 4 patients referred from outpatient clinics lacked formal hemogram results or had pre-initiated antibiotic therapy. A standardized protocol requiring patients to arrive at the ED with a written referral addressed to Internal Medicine and with laboratory testing and antibiotics already initiated could streamline care and reduce avoidable delays. Notably, in our sample, all patients with solid tumors who independently accessed the ED did so during weekends, holidays, or after 2 p.m., periods during which the Day Hospital was unavailable.\u003c/p\u003e\u003cp\u003eIt was not possible to know the real time from triage to medical observation, since medical records are often written later. Nonetheless, significant delays were observed in the time from admission to key clinical milestones, reflecting a clear deviation from international recommendations.\u003c/p\u003e\u003cp\u003eGuidelines advocate initiating empirical antibiotic therapy within the first hour of presentation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this benchmark was not met in our sample. The median time to antibiotic initiation ranged from 4.5 to nearly 8 hours, depending on triage category and referral pathway. Patients triaged with a yellow code, who accounted for more than half of the sample, experienced the longest delays, particularly when referred to General Medicine. In these patients, time to antibiotic administration was nearly twice as long as in those triaged to Internal Medicine. This discrepancy can be partly explained by systemic organizational factors. Within our institution, the General Medicine team is typically responsible for managing patients triaged as lower-priority (green or yellow codes) and operates under significantly more constrained resources, with a high patient-to-physician ratio and broader clinical responsibilities, which may delay the timely assessment and treatment of high-risk individuals inadvertently triaged to their care.\u003c/p\u003e\u003cp\u003eAlthough the MASCC score was significantly associated with in-hospital mortality in our sample (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), it does not fully account for the elevated mortality rate observed (21%), which is more than double the ~\u0026thinsp;10% typically reported in the literature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notably, even when analysing mortality rates within each MASCC category (scores\u0026thinsp;\u0026lt;\u0026thinsp;21 and \u0026ge;\u0026thinsp;21), we found rates higher than those generally expected for both risk groups [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. One plausible contributing factor to this elevated mortality is triage misclassification. Patients with febrile neutropenia who were not promptly identified as high-risk may have experienced significant delays in diagnostic work-up (e.g., hemogram) and initiation of empirical antibiotic therapy, both of which are time-sensitive interventions. As such, while the MASCC index remains a valuable prognostic tool, its predictive power may be limited in real-world settings where organizational and procedural factors - such as triage delays - play a critical role. On the other hand, contrary to international evidence demonstrating a strong association between delayed antibiotic initiation and adverse outcomes, including increased mortality and longer hospital stays, our analysis did not identify a statistically significant correlation between time to antibiotics and either mortality or length of hospitalization [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This apparent discrepancy may be explained by several limitations. The relatively small sample size may have reduced the statistical power needed to detect associations. In addition, the study did not control for potentially important confounding variables such as comorbidities (e.g., cardiovascular disease, diabetes), causative pathogens, multidrug resistance, or the presence of bacteremia - all of which could independently influence clinical outcomes.\u003c/p\u003e\u003cp\u003eFuture research with larger sample sizes and more comprehensive data collection is warranted to clarify these associations and identify which specific clinical and systemic factors most influence outcomes in this vulnerable population.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e This study reveals critical gaps between established guidelines and real-world practice in the management of febrile neutropenia in the ED. The majority of patients failed to receive empirical antibiotic therapy within the recommended first hour after admission, with delays significantly more pronounced in those who received a yellow code and were triaged to General Medicine rather than Internal Medicine. Given the high-risk nature of febrile neutropenia and its associated morbidity and mortality, it is imperative that all oncological patients presenting with fever are systematically referred to Internal Medicine, bypassing generalist pathways that may lead to treatment delays.\u003c/p\u003e\u003cp\u003eThese findings support the implementation of a dedicated internal \u0026ldquo;fast-track\u0026rdquo; protocol for oncological patients with fever. Such a pathway should include (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eImmediate electronic identification of oncological status at the moment of patient triage and fast-track protocol initiated;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAutomatic assignment of an orange code (high-priority);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDirect referral to Internal Medicine or other appropriate specialties;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHemogram and blood cultures obtained within 10 minutes;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eInitiation of empirical antibiotic therapy within 60 minutes;\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIdeally administered after hemogram confirmation, but not delayed beyond 60 minutes if results are unavailable;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStandardized regimens based on hemodynamic stability (e.g., piperacillin-tazobactam if hemodynamically unstable or ceftriaxone if not);\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEarly clinical reassessment to determine outpatient versus inpatient management and adjust treatment.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e Adopting such a protocol would help ensure timely, guideline-adherent care and may reduce preventable delays, morbidity, and mortality in this vulnerable population. Translating theoretical recommendations into clinical practice is essential to improving outcomes for febrile neutropenia patients. We recommend that this analysis be repeated following the implementation of the fast-track protocol, to assess its impact on key clinical metrics such as time to antibiotic initiation and adherence to international benchmarks, hospitalization duration, and mortality. Ideally, this should be conducted as a multi-center study to enhance the generalizability of findings and support broader implementation across healthcare institutions.\u003c/p\u003e\u003cp\u003eFinally, given the rising incidence of cancer worldwide and projections indicating that it may soon become the leading cause of mortality in developed countries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], it is crucial to recognize febrile neutropenia as a frequent and potentially life-threatening complication of oncological treatment. Just as dedicated fast-track pathways exist for conditions such as stroke or myocardial infarction, the implementation of an equally robust protocol for febrile neutropenia is imperative to ensure timely, effective care for this growing patient population.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey Messages\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMost febrile neutropenia patients in the ED did not receive antibiotics within the recommended 60 minutes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDelays in antibiotic administration were more frequent among patients triaged with yellow codes and referred to General Medicine.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThere was no statistically significant correlation between time to antibiotic initiation and length of hospital stay or mortality.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe observed mortality rate was twice as high as reported in the literature.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTimely identification and prioritization of febrile oncological patients is essential for early intervention. A dedicated \u0026ldquo;fast-track\u0026rdquo; protocol may reduce treatment delays, with potential impact on morbidity and mortality.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatements \u0026amp; Declarations\u003c/b\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Alexandra Guedes, Joana Cabral, Beatriz Belo, Sandra Silva, Patr\u0026iacute;cia Liu, Raquel Basto, Joana Marinho, Raquel Monteiro, Adriana Soares, Maria Castelo Branco, Cristiana Marques, Ana Barroso, Henrique Coelho, Jos\u0026eacute; Ribeiro Almeida, Enrique Dias, A. Moreira Pinto, Sandra Cust\u0026oacute;dio, and Andreia Capela. The first draft of the manuscript was written by Alexandra Guedes and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective observational study approved by the institutional ethics committee of the Gaia/Espinho Local Health Unit (Comiss\u0026atilde;o de \u0026Eacute;tica da ULS Gaia/Espinho). The need for informed consent was waived due to the retrospective nature of the study and the use of anonymized patient data. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo additional data is available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKlastersky J, Paesmans M, Rubenstein EB, Boyer M, Elting L, Feld R, et al. The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol. 2000;18(16):3038\u0026ndash;51. https://doi.org/10.1200/JCO.2000.18.16.3038\u003c/li\u003e\n \u003cli\u003eFreifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56\u0026ndash;93. https://doi.org/10.1093/cid/cir073\u003c/li\u003e\n \u003cli\u003eKlastersky J, de Naurois J, Rolston K, Rapoport B, Maschmeyer G, Aapro M, et al. Management of febrile neutropaenia: ESMO clinical practice guidelines. Ann Oncol. 2016;27(Suppl 5):v111\u0026ndash;8. https://doi.org/10.1093/annonc/mdw325\u003c/li\u003e\n \u003cli\u003eFlowers CR, Seidenfeld J, Bow EJ, Karten C, Gleason C, Hawley DK, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2013;31(6):794\u0026ndash;810. https://doi.org/10.1200/JCO.2012.45.8661\u003c/li\u003e\n \u003cli\u003eTam CS, O\u0026rsquo;Reilly M, Andresen D, Fong A, Worth LJ, Slavin MA. Use of empiric antimicrobial therapy in neutropenic fever. Intern Med J. 2011;41 Suppl 1:90\u0026ndash;101. https://doi.org/10.1111/j.1445-5994.2010.02340.x\u003c/li\u003e\n \u003cli\u003ePerron T, Emara M, Ahmed N, Marzouk K, Downey D, Siemens DR. Time to antibiotics and outcomes in cancer patients with febrile neutropenia. BMC Health Serv Res. 2014;14:162. https://doi.org/10.1186/1472-6963-14-162\u003c/li\u003e\n \u003cli\u003eRosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother. 2014;58(7):3799\u0026ndash;803. https://doi.org/10.1128/AAC.02561-14\u003c/li\u003e\n \u003cli\u003eManchester Triage Group. Emergency Triage. 3rd ed. London: BMJ Publishing Group; 2014.\u003c/li\u003e\n \u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209\u0026ndash;49. https://doi.org/10.3322/caac.21660\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1 \u0026ndash;\u003c/strong\u003e Demographic and clinical characteristics of febrile neutropenia patients admitted to the ED (n=38).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e68.2 (\u0026plusmn;9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e n (%)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Male\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (55.3)\u003c/p\u003e\n \u003cp\u003e17 (44.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eECOG performance status\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (21.1)\u003c/p\u003e\n \u003cp\u003e19 (50)\u003c/p\u003e\n \u003cp\u003e10 (26.3)\u003c/p\u003e\n \u003cp\u003e1 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary tumor type\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003eSolid Tumors\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Lung\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Breast\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Head and Neck\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Colorrectal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pancreatic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ovarian\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Leiomyosarcoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bladder\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Hematologic malignancies\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Non-Hodgkin lymphoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acute myeloid leukemia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mielodysplastic syndrome\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Chronic lymphocytic leukemia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Multiple myeloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (57.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 8 (21.1) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 4 (10.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 3 (7.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 3 (7.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u003c/p\u003e\n \u003cp\u003e16 (42.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 9 (23.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 3 (7.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 2 (5.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 1 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutropenia cause\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDisease-related\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Chemotherapy-related\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (10.5)\u003c/p\u003e\n \u003cp\u003e34 (89.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy regimens\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Solid tumors\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Platinum doublet\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Taxane monotherapy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Topotecan monotherapy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Hematologic malignancies\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;R-CHOP\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Azacytidine\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (21.1)\u003c/p\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003cp\u003e10 (26.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since last chemotherapy, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e8.9 (\u0026plusmn;4.4) days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANC at admission\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026lt;500 cells/\u0026micro;L\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026le;100 cells/\u0026micro;L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (100)\u003c/p\u003e\n \u003cp\u003e19 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMASCC risk score\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026ge;21 (low risk)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026lt;21 (high risk)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (68.4)\u003c/p\u003e\n \u003cp\u003e12 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfection site,\u003c/strong\u003e n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Respiratory tract\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Gastrointestinal tract\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Genitourinary tract\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; No identified focus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (40)\u003c/p\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003cp\u003e4 (10.5)\u003c/p\u003e\n \u003cp\u003e12 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2 \u0026ndash;\u003c/strong\u003e Triage and orientation of febrile neutropenia patients admitted to the ED (n=38).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTriage Code\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrientation,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMASCC score, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal,\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternal Medicine / Specialties\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Medicine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eO\u003c/strong\u003e\u003cstrong\u003erange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e13 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e7 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e6 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e13 (34)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYellow\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e11 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e10 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e17 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e21 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e28 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e10 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e12 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e26 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e38 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3 \u0026ndash;\u003c/strong\u003e Clinical outcomes of febrile neutropenia patients admitted to the ED (n = 38).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedicine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Medicine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cem\u003eMann\u0026ndash;Whitney U\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from admission to hemogram,\u003c/strong\u003e median (min; max)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e1h30\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0h42; 6h30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e2h45\u003c/p\u003e\n \u003cp\u003e(0h30; 8h36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003ep = 0.46*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from admission to antibiotics,\u003c/strong\u003e median (min; max)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e4h27\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1h08; 20h32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e7h46\u003c/p\u003e\n \u003cp\u003e(3h04; 45h20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep = 0.03\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Febrile Neutropenia, Emergency Medical Tags, Emergency Department, Manchester Triage","lastPublishedDoi":"10.21203/rs.3.rs-7387709/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7387709/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003eFebrile neutropenia is a frequent complication of oncological treatment. Empirical antibiotic therapy should be started within the first hour after admission. Delays in its administration are associated with prolonged hospital stays and higher mortality rates. Our aim was to assess the impact of Manchester Triage of febrile neutropenia patients admitted to the Emergency Department (ED) on time to antibiotic initiation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients with cancer admitted to the ED of our institution in 2022 who had a diagnosis of febrile neutropenia were selected. Non-oncological patients and children were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Out of 38 patients, 34% were assigned an orange code and 11% a white code (referred from outpatient consultation); all patients in these two groups were directed to Internal Medicine (IM). A yellow triage code was assigned to 55% of patients, who were then directed either to IM or General Medicine (GM), without a defined criterion. Among patients triaged to IM (74%), the median time from admission to initiation of antibiotics was 4h27 (min. 1h08, max. 20h32), while for those triaged to GM (26%), the median was 7h46 (min. 3h04, max. 45h20) (p = 0.03, Mann–Whitney U).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e the data show that delays are significant and worsened when patients are assigned a yellow Manchester Triage code and are not triaged directly to IM. Proper triage of febrile oncological patients in the ED is crucial, and protocols with well-defined criteria should be implemented to ensure timely treatment.\u003c/p\u003e","manuscriptTitle":"Impact of Manchester Triage on the Referral Pathway of Febrile Neutropenia Patients in the Emergency Department – A Single-Center Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 09:14:14","doi":"10.21203/rs.3.rs-7387709/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-30T16:17:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T13:39:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101265321599222817356902159576127714063","date":"2025-10-30T12:18:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T06:05:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193953430922049169434407229628503041331","date":"2025-10-04T01:42:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-01T19:00:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-01T18:57:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T06:36:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-08-16T13:17:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a380e14c-457d-4030-9fe3-3f2daec842cb","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:00:49+00:00","versionOfRecord":{"articleIdentity":"rs-7387709","link":"https://doi.org/10.1007/s00520-026-10400-y","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2026-02-03 15:57:21","publishedOnDateReadable":"February 3rd, 2026"},"versionCreatedAt":"2025-10-15 09:14:14","video":"","vorDoi":"10.1007/s00520-026-10400-y","vorDoiUrl":"https://doi.org/10.1007/s00520-026-10400-y","workflowStages":[]},"version":"v1","identity":"rs-7387709","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7387709","identity":"rs-7387709","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}