Febrile neutropenia (FN) in children treated for malignancy is a common and direct
sequela of chemotherapy. Episodes of FN can be life-threatening, and demand prompt
recognition, assessment and treatment with broad spectrum antibiotics. While in the
majority of episodes no causal infection is identified, 10-20% are secondary to a
bloodstream infection (BSI). A reduction in episodes of BSI could be achieved through
robust infection prevention strategies, such as CVL care bundles. Alongside good antimicrobial
stewardship, these strategies could reduce the risk of emergent, multi-drug resistant
(MDR) infections. Emerging bacterial pathogens in BSI include Viridans Group Streptococci
(VGS) and Enterobacteriaceae such as Klebsiella spp. which are known for their ability
to carry MDR genes. There is also increased recognition of the role of invasive fungal
infection (IFI) in FN, in particular with Aspergillus spp. Novel diagnostics, including
multiplex blood and respiratory polymerase chain reaction assays can identify infections
early in FN, facilitating targeted therapy, and reducing unnecessary antimicrobial
exposure. Given appropriate, and sensitive rapid diagnostics, potential also exists
to safely inform the risk assessment of patients with FN, identifying those at low
risk of complication, who could be treated in the out-patient setting. Several clinical
decision rules (CDR) have now been developed and validated in defined populations,
for the risk assessment of children being treated for cancer. Future research is needed
to develop a universal CDR to improve the management of children with FN.