First, Zotarolimus(ABT-578)? equipment and physicians’ skills to provide complex technical procedures to patients vary betwen hospitals [30]. Barriers can also be related to time consumption of procedures necessary to implement procedures for severe infections. In addition, all team leaders are not fully confident in guidelines to treat severe infections [31]. However, we checked fluid loading and delay to first antimicrobial agent that do not require specific skills or organisation. We observed that these basic treatments were not correctly delivered. In a series of sepsis with hypotension, the delay to antimicrobial agents was over six hours in more than half of patients because infection was not recognised. We believe that most patients were not treated according to guidelines because initial assessment failed to detect the severity of disease.

Despite the efforts in the past decade to produce and distribute specific guidelines for treating severe infection, difficulties persist to detect SS/SSh even in typically at-risk patients such as those with febrile neutropenia.Delay to first antimicrobial agent has an impact on prognosis in patients presenting infection with severity criteria [32]. Guidelines to treat patients with SS/SSh endorse that first dose of antibiotics should be given in a timespan shorter than 90 minutes [9]. Whereas it can be assumed that earlier antimicrobial agents would improve prognosis in febrile neutropenia, no evidence can currently lead to any recommendations about delay. Consequently, guidelines to treating patients with febrile neutropenia are not clear regarding delays to treatment; therefore, objectives are easier to obtain.

This may partly explain why management of patients without SS/SSh frequently reached goals.A puzzling result is that supportive care was not modified by the intervention of the oncologist or haematologist: the presence of a medical unit dedicated to cancer in the same hospital, the existence of written procedures about febrile neutropenia, or the oncologist’s advice did not improve the quality of care. Despite recent validation studies, the relevance of MASCC to guide site of care can be limited because several cornerstone items are missing from this evaluation tool [18]. This supports the fact that the assessment of severity of infection in a short time-span appears to be particularly challenging in onco-haematological patients [33].

The study has several limitations. Whereas simplicity of the study design presumably improved acceptability and feasibility, we cannot rule out Carfilzomib that patients could be missed because making clinical research around the clock is sometimes difficult in busy EDs. Our study did not follow up the patients. It was decided to carry out a descriptive study and patients’ outcomes were not recorded. Thus, it is unknown whether the prognosis of the patients with febrile neutropenia would have changed if recommendations had been implemented.