Broad-Spectrum Antibiotics for Use in Febrile Oncology Patients
If patient is ill-appearing or with signs of shock (i.e. hypotensive requiring > 60 ml/kg fluid resuscitation and/or critical care interventions)***
|
Interventions: · Place IV or access implanted port
· Begin antibiotics STAT · Consider Infectious Diseases (ID) consult if clinically indicated · DO NOT delay antibiotic administration while awaiting labs or ID consult Administer: · Cefepime 50 mg/kg/dose IV q8hrs (max dose: 2,000 mg) -OR- · Vancomycin 15 mg/kg/dose IV q6hrs (max dose: 1,000 mg) PLUS meropenem 20 mg/kg/dose IV q8hrs (max dose: 2,000 mg) |
*** Consider discussion with Infectious Disease on-call as other antimicrobials may also be indicated
If patient is clinically stable, wait for CBC results to determine course of action
|
If patient is neutropenic (ANC < 500 cells/microliter): · Evaluate for discharge eligibility based on Low-Risk Fever and Neutropenia Evaluation clinical pathway o If patient DOES NOT meet low risk criteria: § Administer cefepime 50 mg/kg/dose IV x 1 (max dose: 2,000 mg) STAT § Contact Hem/Onc provider and proceed with admission Alternatives to cefepime in clinically stable patients: § Mild cefepime allergy*: piperacillin/tazobactam 80 mg/kg/dose IV x 1 (max dose: 4,000 mg) § Recent multi-drug resistant infection**: meropenem 20 mg/kg/dose IV x 1 (max dose: 2,000 mg) o If patient DOES meet low risk criteria: § Review patient and provider education per the below clinical pathway § Discharge with levofloxacin per Low-Risk Fever and Neutropenia Treatment clinical pathway |
|
If patient is not neutropenic (ANC > 500 cells/microliter):
· Administer ceftriaxone 50 mg/kg x 1 (max 2,000 mg) · Contact Hem/Onc provider for disposition planning |
*Mild reactions such as rash. Severe reactions such as anaphylaxis or Stevens-Johnson syndrome (SJS) require discussion with Infectious Diseases on-call
**Occurring within the past year; recommend calling Infectious Diseases on-call for additional guidance as other non-carbapenem antibiotics may also be indicated
Additional considerations for empiric antibiotic coverage:
- ADD vancomycin if patient has AML, mucositis/typhlitis, or has a history of MRSA or MRSE or cephalosporin-resistant viridans group streptococci (VGS)
- ADD metronidazole to cefepime for typhlitis or other intra-abdominal infection (do not add to meropenem or piperacillin-tazobactam as these agents have adequate anaerobic coverage)
- Refer to Antibiotics within Sepsis Clinical Pathway for additional guidance
MRSA: methicillin-resistant Staphylococcus aureus
MRSE: methicillin-resistant Staphylococcus epidermidis
VGS examples include: S. mitis, S. oralis, S. anginosus, S. constellatus, S. sanguinis, S. mutans
References
Children’s Oncology Group. (2023, July 14). Guideline for the Management of Fever and Neutropenia in Children with Cancer and/or Undergoing Hematopoietic Stem-Cell Transplantation. https://www.childrensoncologygroup.org/downloads/COG_SC_FN_Guideline_Document.pdf
De Castro, G. C., Slatnick, L. R., Shannon, M., Zhao, Z., Jackson, K., Smith, C. M., Whitehurst, D., Elliott, C., Clark, C. C., Scott, H. F., Friedman, D. L., Demedis, J., & Esbenshade, A. J. (2024). Impact of Time-to-Antibiotic Delivery in Pediatric Patients With Cancer Presenting With Febrile Neutropenia. JCO Oncol Pract, 20(2), 228-238. https://doi.org/10.1200/op.23.00583
Dessie, A. S., Lanning, M., Nichols, T., Delgado, E. M., Hart, L. S., & Agrawal, A. K. (2022). Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care, 38(1), e259-e263. https://doi.org/10.1097/pec.0000000000002241
Ko, B. S., Ahn, S., Lee, Y. S., Kim, W. Y., Lim, K. S., & Lee, J. L. (2015). Impact of time to antibiotics on outcomes of chemotherapy-induced febrile neutropenia. Support Care Cancer, 23(9), 2799-2804. https://doi.org/10.1007/s00520-015-2645-5
Koenig, C., Kuehni, C. E., Bodmer, N., Agyeman, P. K. A., Ansari, M., Roessler, J., von der Weid, N. X., & Ammann, R. A. (2022). Time to antibiotics is unrelated to outcome in pediatric patients with fever in neutropenia presenting without severe disease during chemotherapy for cancer. Sci Rep, 12(1), 14028. https://doi.org/10.1038/s41598-022-18168-x
Oncologic Emergency Guidelines - Children’s Mercy Kansas City. Topic: Fever and Neutropenia (F&N). Retrieved June 29, 2023 from https://scope.cmh.edu/siteassets/uploadedfiles/departments/hematology-oncology-clinic/fever-and-neutropenia-guidelines.pdf
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.