Fever, Non-Oncology CVC Clinical Pathway – Emergency Department – Antibiotic Recommendations and Dosing

Fever, Non-Oncology CVC Clinical Pathway – Emergency Department

Antibiotic Recommendations and Dosing

Fever is a common presenting complaint and may be the first indicator of bacteremia in children with central venous catheters (CVC). Therefore, broad-spectrum antibiotics are indicated as initial treatment as soon as possible. The bacteremia rates are based on type of central venous catheter and underlying disease process. Initial antibiotic therapy is therefore tailored to these characteristics, local susceptibility patterns CHOP antibiogram and previous positive cultures. The most common organisms causing bacteremia in children with CVC are:

  • Coagulase-negative Staphylococcus
  • Staphylococcus aureus (both MRSA and MSSA)
  • Enterobacterales species (e.g., Escherichia coli Klebsiella pneumoniae)
  • Pseudomonas aeruginosa
  • Enterococcus faecalis

Based on these data, broad-spectrum antibiotics are indicated as initial treatment and administered as soon as possible. Initial antibiotic therapy is tailored to individual patient characteristics (underlying disease process, previous positive cultures and sensitivities, etc.) and based on local organism susceptibility patterns. (CHOP antibiogram).

Patient Population First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Additional/Alternative Antibiotics
  • Intestinal Failure
  • Home Parental Nutrition
  • Complex Care Service
  • Sickle Cell Disease with Apheresis Port
  • Hemophilia with Broviac/PICC
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • Ciprofloxacin, IV
    • 10 mg/kg/dose every 12 hours
    • Max: 400 mg/dose
  • and
  • Vancomycin, IV
    • ≤ 50 kg and < 18 years:
      • 15 mg/kg/dose every 6 hours
      • Max: 750 mg/dose
    • > 50 kg or ≥ 18 years:
      • 15 mg/kg/dose every 8 hours
      • Max: 1000 mg/dose
 Ill appearance, history of MRSA, suspected MRSA infection, concern for CNS infection or non-central line indwelling hardware, add vancomycin if not recommended routinely
  • Vancomycin, IV
    • ≤ 50 kg and < 18 years:
      • 15 mg/kg/dose every 6 hours
      • Max: 750 mg/dose
    • > 50 kg or ≥ 18 years:
      • 15 mg/kg/dose every 8 hours
      • Max: 1000 mg/dose
  • Note
    • Vancomycin is routinely recommended in combination with fluoroquinolones given limited activity of fluoroquinolones against Staphylococcus aureus
    • For MDRO (including ESBL, CRE, or RGN listed history, or positive culture within the past 1 year) antibiotics should be individualized based on prior susceptibilities
      • Consider ID consult
  • Liver Transplant
  • Concern for Intra-Abdominal Infection
  • Piperacillin-tazobactam, IV
    • 100 mg piperacillin/kg/dose
      every 6 hours
    • Max: 4000 mg/dose
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Metronidazole, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 1500 mg/day
  • Metabolic Disease with Port
  • Hemophilia with Port
  • Ceftriaxone, IV
    • 75 mg/kg/dose every 24 hours
    • Max: 2000 mg/dose
  • Ciprofloxacin, IV
    • 10 mg/kg/dose every 12 hours
    • Max: 400 mg/dose
  • and
  • Vancomycin, IV
    • ≤ 50 kg and < 18 years:
      • 15 mg/kg/dose every 6 hours
      • Max: 750 mg/dose
    • > 50 kg or ≥ 18 years:
      • 15 mg/kg/dose every 8 hours
      • Max: 1000 mg/dose
Hemodialysis (HD)
  • Cefepime, IV
    • 25 mg/kg/dose every 24 hours split between both HD lumens
    • Max: 1000 mg/dose
  • and
  • Vancomycin, IV
    • 10 mg/kg/dose × 1 dose split between both HD lumens
    • Max: 750 mg/dose
  • Ciprofloxacin, IV
    • 10 mg/kg/dose every 24 hours split between both HD lumens
    • Max: 400 mg/dose
  • and
  • Vancomycin, IV
    • 10 mg/kg/dose × 1 dose split between both HD lumens
    • Max: 750 mg/dose
  • For MDRO (including ESBL, CRE, or RGN listed history consider or positive culture within the past 1 year), antibiotics should be individualized based on prior susceptibilities
    • Consider ID consult

CHOP Formulary for complete drug information.