HemeOnc - Fever and Neutropenia 2013

PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE:
FEVER AND NEUTROPENIA

Population: Patients with known or suspected neutropenia and fever > 38.5 °C (101°F)
Patients at highest risk include those with known cancer and recent chemotherapy
Includes patients with a history of fever at home who present without fever at triage
Triage: Should be placed into an examination room (preferably the isolation room if available) on arrival
and triage is completed in the room
The Attending is notified at the time of the arrival
The Attending evaluates the patient initially at arrival and completes the Fever and Neutropenia
order set in order to expedite timely care
History and Physical Examination:

General appearance and assessment of vital signs (including pulse oximetry)
Rapid Cardiopulmonary assessment
Detailed history, including:
o Primary oncologic diagnosis (including if relapsed disease)
o Chemotherapy received within the previous 2 weeks, namely those agents that are
myelosuppressive, including oral agents
o Other current immunosuppressive medications
o Recent antimicrobial exposure (including prophylaxis)
o Infection history
o Co-morbidities
Site-specific history and physical, including:
o Alimentary canal (oral mucosa, pharynx, esophagus, bowel, rectum)
o Skin
o Vascular access sites
o Perivaginal/perirectal areas
General physical examination for evidence of focal infection
o Mouth and oral pharynx
o Skin
o Catheter line site
Review of systems
o URI symptoms
o Sinus tenderness/symptoms
o Odynophagia
o Nausea and/or emesis
o Abdominal pain
o Diarrhea
o Shortness of breath/cough
o New rash/skin lesions
o Headache/neck stiffness/altered mentation
Evaluation of perfusion, degree of pallor
Neurological evaluation
Diagnostic evaluation:
CBC with differential and calculation of ANC (Absolute Neutrophil Count)
ER 1 and ER2
REVISED Page 1 of 3
12/2/2013
Blood culture
o If there is an indwelling line (central line/PortaCath) you may draw from this line, and an
additional peripheral culture is not necessary.
Type & Screen
U/A and Urine culture
o Do not catheterize patients who may be neutropenic
o Do not withhold antibiotics waiting for patients to produce urine
o Do not perform rectal exams or rectal temperatures on patients who may be neutropenic
CXR if indicated (cough, crackles, tachypnea, abdominal pain)
Attempts should be made to access the medical records. The medical record often contains
detailed clinic notes and discharge summaries with a wealth of information (i.e., lab summaries,
discharge medications, dosages, prior complications).
Therapeutic interventions:
Establish IV access
o D5 NS @ maintenance (1200cc/m2/d)
o Patients with evidence of decreased perfusion may be bolused with 10-20cc/kg of NS
o Excess fluids should be avoided
Administer parenteral antibiotics stat
o Antibiotics should be ordered at the same time as triage and prior to waiting for the
results returning from the lab.
o Ceftazidime 50mg/kg (max 2g)
 ID approval is not needed for ceftazidime for patients with febrile neutropenia
 preferred agent for initial management of pediatric febrile neutropenia
o Consider gentamicin in those with septic physiology or suspicion of resistant
gram-negative organism
o Consider adding Vancomycin 15mg/kg/dose
 Suspected catheter-related infection
 Suspected bacterial meningitis
 Concern for bacterial pneumonia
 Blood culture positive for Gram-positive organism prior to final identification
 Presence of septic physiology
 Known colonization with MRSA with history of previous invasive infection
 Skin and/or soft tissue infection
o Consider adding Azithromycin if infiltrate on CXR (10mg/kg x 1d, 5mg/kg/d x 4)
o Consider addition of anaerobic coverage with clindamycin or metronidazole for those
with: severe mucositis, suspected sinusitis, intra-abdominal process (e.g. typhlitis), or
perirectal pathology
Antipyretics:
o Acetaminophen 15 mg/kg/dose q 4hrs
 Only give orally
 Do not give rectally
o Do not give ibuprofen
Notification of Hematology-Oncology Service

The Hematology-Oncology service should be notified of all oncology patients.
REFERENCES:
1. Alexander SW, Wade KC, Hibberd PL, Parsons SK. Evaluation of risk prediction criteria for
episodes of febrile neutropenia in children with cancer. J Pediatr Hematol Oncol 2002;24:38-42.
2. Chuang YY, Hung IJ, Yang CP, et al. Cefepime versus ceftazidime as empiric monotherapy for
fever and neutropenia in children with cancer. Pediatr Infect Dis J 2002;21:203-9.
REVISED Page 2 of 3
12/2/2013
3. Madsen K, Rosenman M, Hui S, Breitfeld PP. Value of electronic data for model validation and
refinement: Bacteremia risk in children with fever and neutropenia. J Pediatr Hematol Oncol
2002;24:256-62.
4. Orudjev E, Lange BJ. Evolving concepts of management of febrile neutropenia in children with
cancer. Med Pediatr Oncol 2002;39:77-85.
5. Park JR, Coughlin J, Hawkins D, et al. Ciprofloxacin and amoxicillin as continuation treatment of
febrile neutropenia in pediatric cancer patients. Med Pediatr Oncol 2003;40:93-8.
6. Paul M, Soares-Weiser K, Leibovici L. Beta lactam monotherapy versus beta lactam-
aminoglycoside combination therapy for fever with neutropenia: Systematic review and meta-
analysis. BMJ 2003;326:1111.
7. Rosenman M, Madsen K, Hui S, Breitfeld PP. Modeling administrative outcomes in fever and
neutropenia: Clinical variables significantly influence length of stay and hospital charges. J Pediatr
Hematol Oncol 2002;24:263-8.
8. Alexander SW, Wade KC, Hibberd PL, et al. Evaluation of risk prediction criteria for episodes of
febrile neutropenia in children with cancer. Journal of Pediatric Hematology/Oncology. 2002;
24:38-42.
9.
10. Chuang YY, Hung IJ, Yang CP, et al. Cefepime versus ceftazidime as empiric monotherapy for
fever and neutropenia in children with cancer. The Pediatric Infectious Disease Journal. 2002;
21:203-09.
11.
12. Freifeld AG, Bow EJ, SEpkowitz KA, 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. Clinical Infectious Diseases. 2011; 52:e56-93.
13.
14. Hakim H, Flynn PM, Srivastava DK, et al. Risk prediction in pediatric cancer patients with fever
and neutropenia. The Pediatric Infectious Disease Journal. 2010; 29:53-59.
15.
16. Lehrnbecher T, Phillips R, Alexander S, et al. Guideline for the management of fever and
neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplant.
Journal of Clinical Oncology. 2012; 30:4427-38.
17.
18. Manji A, Lehrnbecher T, Dupuis LL, et al. A meta-analysis of antipseudomonal penicillins and
cephalosporins in pediatric patients with fever and neutropenia. The Pediatric Infectious Disease
Journal. 2012; 31:353-59.
19.
20. Mustafa MM, Carlson L, Tkaczewski I, et al. Comparative study of cefepime versus ceftazidime
in the empiric treatment of pediatric cancer patients with fever and neutropenia. The Pediatric
Infectious Disease Journal. 2001; 20-362-69.
DISCLAIMER:
This clinical guideline has been developed for the purpose of unifying the general emergency care of
patients with fever and neutropenia. It is intended to aid, rather than substitute for, professional judgment. It
is not intended to serve as a rigid protocol or a written proxy for the standard of care. Failure to comply
with this guideline does not represent a breach of the standard of care.
REVISED Page 3 of 3
12/2/2013

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PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE:

FEVER AND NEUTROPENIA

History and Physical Examination:

Notification of Hematology-Oncology Service

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