Clinical tools for oncology professionals

CISNE (Clinical Index of Stable febrile Neutropenia)

Used to identify patients with febrile neutropenia who are at risk of medical complications despite appearing clinically stable.

Use only if all criteria below apply:

  • Aged ≥ 18 years
  • Solid cancer receiving mild/moderate intensity chemotherapy
  • Neutrophil count ≤0.5 x109/L or ≤1 and expected to decrease to ≤0.5
  • Absence of organ failure (renal, cardiac, respiratory)
  • Absence of hypotension (systolic≤90mmHg) or septic shock
  • Absence of chronic organ insufficiency
  • Absence of known severe infections

ECOG Performance Status

0 or 1 0 points
≥2 2 points

Hyperglycaemia? CBG≥ 6.7mmol/L or ≥13.9mmol/L if diabetic or on steroids

No 0 points
Yes 2 points

History of COPD? Emphysema, chronic bronchitis, decrease in forced expiratory volumes or need for oxygen therapy, corticosteroids or bronchodilators.

No 0 points
Yes 1 points

Cardiovascular disease? Cor pulmonale, heart failure, cardiomyopathy, hypertensive heart disease, valvular heart disease or other structural malformations. Single uncomplicated episode of AF not included here.

No 0 points
Yes 1 points

Mucositis grade ≥2? Presence of patchy ulcerations or pseudomembranes; or moderate pain with modified diet indicated

No 0 points
Yes 1 points

Monocyte count

≥0.2x109/L 0 points
<0.2x109/L 1 points

CISNE (Clinical Index of Stable febrile Neutropenia) score calculator


Patients with febrile neutropenia who go on to develop medical complications may appear clinically well initially due to their temporary inability to mount an inflammatory response.

The CISNE tool categorises patients into 3 prognostic groups as follows:

CISNE score Risk of complications Risk category
0 1.1% (95% CI 0.3-3.8%) Low
1-2 6.1% (95% CI 4-9%) Intermediate
≥3 32.5% (95% CI 27-38.5%) High

The CISNE tool is designed for use in patients with solid tumours presenting with febrile neutropenia who are stable based on history and clinical examination.

This means the tool should not be used in patients who are considered high risk on initial assessment. These are patients with acute organ failure (cardiac, renal, respiratory), have decompensation of chronic organ failure, who are in septic shock or hypotensive (systolic BP<90mmHg) or have severe infections (e.g. pneumonia, cellulitis>5cm, meningitis, pyelonephritis or enteritis grade 3/4 etc).

The CISNE tool can be used to identify and delay premature discharge of patients with febrile neutropenia who are clinically stable but have underlying risk factors for medical complications.

The CISNE tool was originally developed in a cohort of 861 patients with febrile neutropenia1 and subsequently validated in a multi-centre study of 1133 patients2. In a further independent validation study of 230 patients, a low-risk CISNE score was identified in 53 (23%) patients and was highly specific for absence of adverse outcomes (upgrade in level of care, clinical deterioration, bacteraemia and death) with 98% specificity and 99.9% positive predictive value3.

See also the MASCC tool.

  1. Carmona-Bayonas A, Gomez J, Gonzalez-Billalabeitia E, et al. Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients. Br J Cancer. 2011;105(5):612-617. doi:10.1038/bjc.2011.284
  2. Carmona-Bayonas A, Jimenez-Fonseca P, Virizuela Echaburu J, et al. Prediction of serious complications in patients with seemingly stable febrile neutropenia: validation of the Clinical Index of Stable Febrile Neutropenia in a prospective cohort of patients from the FINITE study. J Clin Oncol Off J Am Soc Clin Oncol. 2015;33(5):465-471. doi:10.1200/JCO.2014.57.2347
  3. Coyne CJ, Le V, Brennan JJ, et al. Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department. Ann Emerg Med. 2017;69(6):755-764. doi:10.1016/j.annemergmed.2016.11.007