MASCC — Febrile Neutropenia Risk Score
Burden of febrile neutropenia illness
What is Febrile Neutropenia MASCC Score?
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Febrilná neutropénia (FN) je bežnou a potenciálne život ohrozujúcou komplikáciou chemoterapie rakoviny, ktorá je definovaná ako jednorazová orálna teplota nad 38,3 °C alebo teplota nad 38,0 °C trvajúca dlhšie ako jednu hodinu u pacienta s absolútnym počtom neutrofilov (ANC) nižším ako 500 buniek/µl alebo s očakávaným poklesom ANC pod 500 buniek/µl za hodinu. FN vyžaduje okamžité lekárske vyšetrenie, pretože neutropenickým pacientom chýba schopnosť vyvolať účinnú imunitnú odpoveď proti bakteriálnym a plesňovým patogénom, čo ich vystavuje vysokému riziku sepsy a smrti bez rýchlej antibiotickej liečby. Stratifikácia rizika v čase prezentácie FN je kritická pre určenie, či pacient môže byť liečený perorálnymi antibiotikami doma alebo či si vyžaduje intravenózne antibiotiká a hospitalizáciu. Index rizika Medzinárodnej asociácie pre podpornú starostlivosť pri rakovine (MASCC) je najrozšírenejším nástrojom na tento účel. Skóre MASCC používa sedem klinických premenných: záťaž chorobou (hodnotená podľa závažnosti príznakov a symptómov FN, 0–5 bodov), absencia hypotenzie (5 bodov), absencia chronickej obštrukčnej choroby pľúc (4 body), solídny nádor alebo lymfóm bez predchádzajúcej mykotickej infekcie (4 body), absencia dehydratácie (3 body), ambulantný stav pri nástupe horúčky (3 body) a vek pod 2 roky. Maximálne skóre MASCC je 26. Skóre 21 alebo vyššie identifikuje pacientov ako nízkorizikových – definovaných ako pacientov s menej ako 5 % rizikom závažných zdravotných komplikácií – ktorí môžu byť kandidátmi na perorálnu antibiotickú liečbu (ciprofloxacín + amoxicilín-klavulanát) a skoré prepustenie alebo ambulantnú liečbu. Pacienti so skóre MASCC pod 21 sú klasifikovaní ako vysokorizikoví a vyžadujú hospitalizáciu a intravenózne širokospektrálne antibiotiká.
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Vzorec
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Skóre MASCC = body (záťaž chorobou) + body (bez hypotenzie) + body (bez CHOCHP) + body (solidný nádor/lymfóm bez predchádzajúcej mykotickej infekcie) + body (bez dehydratácie) + body (ambulantný pacient pri nástupe horúčky) + body (vek < 60); Skóre ≥ 21 = nízke rizikoVariable Legend
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| Symbol | Meno | Jednotka | Popis |
|---|---|---|---|
| ANC | Absolútny počet neutrofilov | cells/µL | The total count of neutrophils (segmented and band neutrophils) in peripheral blood. FN is defined when ANC falls below 500 cells/µL or is expected to do so within 48 hours. |
| MASCC | MASCC Risk Index Score | points (0–26) | Composite score from seven clinical variables used to stratify febrile neutropenia patients into low risk (≥21) and high risk (<21) groups for management decisions. |
| SBP | Systolický krvný tlak | mmHg | Haemodynamic stability indicator. Hypotension (SBP <90 mmHg) scores 0 on the MASCC and is an absolute indicator for hospital admission and IV antibiotics. |
How to Febrile Neutropenia MASCC Score
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- 1Posúďte záťaž febrilného ochorenia pri prezentácii: 5 bodov za žiadne/mierne symptómy, 3 body za stredne závažné symptómy, 0 bodov za závažné symptómy (jediná premenná, kde vyššie symptómy dávajú nižšie skóre).
- 2Stanovte krvný tlak: priraďte 5 bodov, ak je systolický TK ≥90 mmHg (bez hypotenzie). Hypotenzia (SBP <90) má pre túto zložku skóre 0.
- 3Posúdenie známej chronickej obštrukčnej choroby pľúc (CHOCHP) alebo aktívnej choroby pľúc: 4 body, ak pacient nemá žiadnu CHOCHP alebo aktívnu chronickú chorobu pľúc.
- 4Posúdenie typu nádoru a anamnézy infekcie: 4 body, ak má pacient solídny nádor alebo hematologickú malignitu bez predchádzajúcej mykotickej infekcie. Pacienti s predchádzajúcou dokumentovanou invazívnou mykotickou infekciou alebo hematologickou malignitou s predchádzajúcim plesňovým ochorením skóre 0.
- 5Posúďte stav hydratácie: 3 body, ak žiadna významná dehydratácia nevyžadujúca IV tekutiny. Dehydratácia vyžadujúca IV tekutiny má skóre 0.
- 6Posúďte nastavenie nástupu: 3 body, ak bol pacient v čase vzniku horúčky ambulantný. Nástup horúčky v nemocnici skóre 0.
- 7Posúdiť vek: 2 body, ak je pacient mladší ako 60 rokov. Vek 60 alebo viac rokov skóre 0. Spočítajte všetky zložky. Skóre ≥21 = nízke riziko (môžu byť vhodné ambulantné antibiotiká); skóre <21 = vysoké riziko (hospitalizovať a podávať IV antibiotiká).
Worked Examples
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Vhodné na perorálny ciprofloxacín + amoxicilín-klavulanát a výtok s 24-hodinovou kontrolou
Maximálne skóre MASCC znamená, že pacient má menej ako 5 % riziko závažných zdravotných komplikácií. Vhodné sú ambulantné perorálne antibiotiká s prísnymi opatreniami na návrat a 24-hodinovým telefonickým/klinickým vyšetrením.
Okamžité IV širokospektrálne antibiotiká; hodnotenie JIS; pravdepodobne bude potrebná antifungálna liečba
Skóre MASCC 0 predstavuje maximálne klinické riziko. Tento pacient vyžaduje okamžité empirické IV antibiotiká (piperacilín-tazobaktám alebo meropeném), pravdepodobné antimykotické krytie a intenzívne sledovanie.
Score ≥21 suggests low risk, but age ≥60 with lymphoma warrants careful clinical assessment before discharge
While the MASCC score of 22 meets the low-risk threshold, the borderline score combined with age 62 and lymphoma diagnosis warrants careful clinical review, blood culture results, and close follow-up before confirming outpatient management.
Inpatient FN always requires IV antibiotics initially regardless of MASCC score; MASCC guides step-down to oral after 48h
Inpatient-onset FN should always be treated initially with IV antibiotics. A high MASCC score in this context supports early step-down to oral antibiotics after 48 hours of clinical stability.
Real-World Applications
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Primary care physicians and internists use Febrile Neutropenia Risk during routine clinical assessments to screen patients, establish baselines for longitudinal monitoring, and identify individuals who may need referral to specialists for further diagnostic evaluation or therapeutic intervention.
Hospital clinical pharmacists apply Febrile Neutropenia Risk to verify drug dosing calculations, particularly for medications with narrow therapeutic indices like warfarin, aminoglycosides, and chemotherapy agents where patient-specific factors such as renal function and body weight critically affect safe dosing ranges.
Public health epidemiologists use Febrile Neutropenia Risk in population-level screening programs to calculate disease prevalence, assess screening test sensitivity and specificity, and determine the number needed to screen to detect one case in various demographic subgroups.
Clinical researchers incorporate Febrile Neutropenia Risk into study design protocols to calculate sample sizes, determine statistical power for detecting clinically meaningful differences, and establish inclusion criteria based on quantitative physiological thresholds.
Special Cases
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Referenčné rozsahy pre deti a dospelých
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in febrile neutropenia risk calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
Tehotenstvo a hormonálne zmeny
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in febrile neutropenia risk calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
Extrémne zloženie tela
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in febrile neutropenia risk calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
FN in elderly cancer patients
Age 60 or above automatically excludes the 2-point MASCC age bonus, making it harder for elderly patients to reach the low-risk threshold of 21. Elderly patients also have more comorbidities and are more likely to decompensate rapidly, so caution is advised even if MASCC suggests low risk.
MASCC Risk Index Score Components
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| Variabilné | Body | Scoring Criterion |
|---|---|---|
| Burden of illness — no/mild symptoms | 5 | Patient has no or only mild FN symptoms |
| Burden of illness — moderate symptoms | 3 | Patient has moderate FN-related symptoms |
| Burden of illness — severe symptoms | 0 | Patient has severe FN-related symptoms |
| No hypotension (SBP ≥ 90 mmHg) | 5 | Systolic BP ≥90 mmHg at presentation |
| No COPD | 4 | Patient has no chronic obstructive pulmonary disease |
| Solid tumour or lymphoma/no prior fungal | 4 | Solid tumour, or haematological malignancy without prior invasive fungal infection |
| No dehydration requiring IV fluids | 3 | No clinical dehydration requiring intravenous fluid resuscitation |
| Outpatient status at fever onset | 3 | Fever developed while patient was an outpatient |
| Age < 60 years | 2 | Patient is younger than 60 years at time of FN episode |
| Maximum score | 26 | Score ≥21: Low risk; Score <21: High risk |
Frequently Asked Questions
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What is febrile neutropenia?
Febrile neutropenia is defined as a temperature above 38.3°C once or above 38.0°C sustained for one hour, occurring in a patient with an absolute neutrophil count (ANC) below 500 cells/µL or expected to fall below 500 cells/µL within 48 hours. It is a medical emergency in cancer patients and requires immediate evaluation and empirical antibiotic therapy.
What is the most common cause of febrile neutropenia?
Febrile Neutropenia Risk is a specialized calculation tool designed to help users compute and analyze key metrics in the health and medical domain. It takes specific numeric inputs — typically drawn from real-world data such as measurements, rates, or quantities — and applies a validated mathematical formula to produce actionable results. The tool is valuable because it eliminates manual calculation errors, provides instant feedback when exploring different scenarios, and serves as both a decision-support instrument for professionals and a learning aid for students studying the underlying principles.
What is the CISNE score and how does it differ from MASCC?
The Clinical Index of Stable Febrile Neutropenia (CISNE) is an alternative validated risk stratification tool, specifically derived for patients with solid tumours and apparently stable FN. CISNE uses different variables including ECOG performance status, chronic cardiovascular disease, strict monocytes criterion, and presence of stress hyperglycaemia. Some studies suggest CISNE outperforms MASCC for solid tumour populations specifically.
How long should antibiotics be given for febrile neutropenia?
Antibiotic duration depends on ANC recovery and defervescence. For low-risk patients, oral antibiotics are continued until afebrile for 48 hours and ANC >500 cells/µL. For high-risk patients on IV antibiotics, treatment continues until ANC recovery and sustained apyrexia. Minimum durations are typically 4–7 days even if early clinical improvement occurs.
Should antifungal therapy be added empirically?
Use Febrile Neutropenia Risk whenever you need a reliable, reproducible calculation for decision-making, planning, comparison, or verification. Common triggers include evaluating a new opportunity, comparing two or more alternatives, checking whether a quoted figure is reasonable, preparing documentation that requires precise numbers, or monitoring changes over time. In professional settings, recalculating regularly — especially when key inputs change — ensures that decisions are based on current data rather than outdated estimates. Students should use the tool after attempting manual calculation to verify their understanding of the formula.
Common Mistakes to Avoid
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- !Misscoring the burden of illness component — it is the only variable that is NOT binary; it is a 3-tier (0/3/5) assessment of symptom severity, not a yes/no question.
- !Assuming MASCC ≥21 alone is sufficient to discharge without confirming other discharge eligibility criteria: adequate social support, reliable telephone access, proximity to hospital, patient and caregiver understanding of return precautions.
- !Failing to take blood cultures before administering the first antibiotic dose — cultures must be collected prior to antibiotics to maximise pathogen yield, which guides de-escalation.
- !Using MASCC in haematology patients receiving myeloablative chemotherapy — these patients have prolonged expected neutropenia and should always be admitted regardless of initial MASCC score.
- !Not reassessing MASCC if the patient deteriorates in the first few hours — a patient who was MASCC 21 on arrival and then becomes hypotensive at hour 4 has crossed into high-risk territory requiring escalation.
- !Forgetting to start G-CSF prophylaxis for subsequent cycles after an episode of FN — a history of FN on a particular regimen is the clearest indication for secondary G-CSF prophylaxis in future cycles.
Pro Tip
Always take at least two sets of blood cultures (peripheral and from each lumen of any central venous catheter) BEFORE administering the first antibiotic dose. The window for positive cultures closes rapidly once antibiotics are started, and pathogen identification is essential for rational antibiotic de-escalation and duration decisions.
Did you know?
The MASCC risk index was derived from a prospective study of over 1,000 FN episodes across 14 centres in 11 countries — making it one of the most internationally representative FN datasets ever assembled. The study was specifically designed to challenge the then-universal practice of hospitalising all FN patients, proving that a substantial proportion could be managed safely at home and revolutionising FN care worldwide.
Regional Guides
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🇬🇧 UK▾
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References
- ›Klastersky J et al. The Multinational Association for Supportive Care in Cancer risk index. J Clin Oncol 2000.
- ›Freifeld AG et al. IDSA Clinical Practice Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients. Clin Infect Dis 2011.
- ›ASCO Clinical Practice Guideline: Recommendations for the Use of WBC Growth Factors. J Clin Oncol 2015.
- ›ESMO Clinical Practice Guidelines: Febrile Neutropenia. Ann Oncol 2016.
- ›MDCalc — MASCC Risk Index for Febrile Neutropenia
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