Oncology Patient Presenting with New Fever Clinical Pathway – Emergency Department and Outpatient Specialty Care – Choosing the Antibiotics

Oncology Patient Presenting with New Fever Clinical Pathway

Antibiotic Recommendations

In children with chemotherapy-induced neutropenia, the rate of documented infection is between 10–40%. Children with chemotherapy-induced neutropenia and a central venous catheter are at increased risk for bacteremia, so empiric broad-spectrum antibiotics are indicated.

Most Common Gram-Positive Pathogens Most Common Gram-Negative Pathogens
  • Coagulase-negative staphylococci
  • Viridans group streptococci
  • Staphylococcus aureus
  • Enterobacterales (e.g., Escherichia coli, Klebsiella spp and Enterobacter spp)
  • Pseudomonas aeruginosa

Vancomycin Indications

  • AML or relapsed ALL receiving four drug re-induction therapy (discuss with Oncology)
  • BMT during pre-engraftment neutropenia
  • Child with a history of MRSA (colonization or infection) and currently with suspected MRSA infection (skin/soft tissue infection, including line exit site, lobar PNA)
  • Concern for CNS infection
  • Non-central line indwelling hardware (VP shunt, pacemaker, etc.)
  • Concern for septic shock—see Sepsis Pathway

General Oncology, Autologous Stem Cell Transplant Presenting as an Outpatient, CAR T-cell Therapy ≥ 1 Month

Patient Population First-Line Treatment Allergy to First-Line β-Lactam
Assess Need for Alternative
Broviac, PICC Line, Medcomp/Pheresis Catheter (Regardless of Neutropenia)
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hrs
    • Max: 2000 mg/dose
  • Most children do not require vancomycin—add vancomycin if child meets one or more indications above for vancomycin use:
  • Vancomycin, IV
    • 15 mg/kg/dose every 6 hours
    • Max: 500 mg/dose
  • Aztreonam, IV
    • 40 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Clindamycin, IV
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
Port or No Line and ANC < 200 Does Not Meet Outpatient Criteria
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Most children do not require vancomycin—add vancomycin if child meets one or more indications above for vancomycin use:
  • Vancomycin, IV
    • 15 mg/kg/dose every 6 hours
    • Max: 500 mg/dose
  • Aztreonam, IV
    • 40 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Clindamycin, IV
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
Meets Outpatient Criteria
  • Levofloxacin, Oral
    • < 5 years of age: 10 mg/kg/dose every 12 hours
    • Max: 250 mg/dose
    • ≥ 5 years of age: 10 mg/kg/dose every 24 hours
    • Max: 750 mg/dose
Port and ANC ≥ 200
  • Ceftriaxone, IV
    • 75 mg/kg/dose every 24 hours
    • Max: 2000 mg/dose
  • Ertapenem, IV
    • Infants ≥ 3 months of age, children < 13 years of age: 15 mg/kg/dose twice daily
    • Max: 500 mg/dose
    • Adolescents ≥ 13 years of age: 1000 mg once daily
No Line and ANC ≥ 200 No antibiotics indicated based on oncologic history – assess for focal bacterial infection as clinically indicated

CHOP Formulary for complete drug information.

CAR T-cell Therapy < 1 Month, Allogeneic Stem Cell Transplants, Stem Cell Based Gene Therapy Receipients, and Autologous Stem Cell Transplants During the Transplant Hospitalization

Patient Population First-Line Treatment Allergy to First-Line β-Lactam
Assess Need for Alternative
  • CAR T-cell < 1 mo
  • Allogeneic stem cell
    transplant or gene therapy recipients < 6 mos
  • Allogeneic stem cell
    transplant or gene therapy recipient ≥ 6 mos either on immunosuppressive therapy or ANC < 200
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • Most children do not require vancomycin—add vancomycin if child meets one or more indications above for vancomycin use:
  • Vancomycin, IV
    • 10 mg/kg/dose every 6 hours
    • Max: 500 mg/dose
  • Aztreonam, IV
    • 40 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Clindamycin, IV
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
Allogeneic stem cell
transplant or gene therapy recipient ≥ 6 mos not on immunosuppressive therapy and ANC ≥ 200		 Broviac/PICC
  • Cefepime, IV
    • 50 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • Add vancomycin if child meets one or more indications above for vancomycin use:
  • Vancomycin, IV
    • 10 mg/kg/dose every 6 hours
    • Max: 500 mg/dose
  • Aztreonam, IV
    • 40 mg/kg/dose every 8 hours
    • Max: 2000 mg/dose
  • and
  • Clindamycin, IV
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
Port or No Line with Antibiotic Prophylaxis (e.g., Amoxicillin, Penicillin, Erythromycin)
  • Ceftriaxone, IV
    • 75 mg/kg/dose every 24 hours
    • Max: 2000 mg/dose
  • Ertapenem, IV
    • Infants ≥ 3 months of age, children < 13 years of age: 15 mg/kg/dose twice daily
    • Max: 500 mg/dose
    • Adolescents ≥ 13 years of age: 1000 mg once daily
No Line without Antibiotic Prophylaxis
No antibiotics indicated

CHOP Formulary for complete drug information.

Additional Special Considerations for Initial Antibiotic Choices in Oncology Patient with Fever

Child with Septic Shock
Requiring Vasopressor
Child Already on Broad-Spectrum Antibiotics at the Time of Fever
Any regimen including ceftriaxone, ceftazidime, cefepime, piperacillin-tazobactam, ertapenem, levofloxacin, or aztreonam alone or in combination with clindamycin or vancomycin
 Choice of antibiotic(s) and/or antifungals may be individualized, considering previous antibiotic exposures and suspected source of infection; discuss with ID as needed based on individual circumstances
Suspected Intra-Abdominal
(e.g., Typhlitis) or Perirectal Source
  • Cefepime + metronidazole
  • or
  • Piperacillin/tazobactam
MRSA History
  • Add vancomycin only if suspected MRSA infection
    • e.g., line exit site infection, lobar pneumonia
VRE History
  • Empiric coverage not recommended unless child has septic shock requiring vasopressors
  • Consider empiric coverage with linezolid in children with septic shock requiring vasopressors
Resistant Gram-Negative
Organism History
  • Review MDRO history and last 12 mos of cultures – attention to third-generation cephalosporin non-susceptible organisms (which include ESBL producers) and carbapenem-resistant organisms (e.g., CRE)
  • Discuss with Oncology, Infectious Disease
Global Medicine Patient
  • Inpatients: replace cefepime with meropenem
  • Outpatients: discuss with Oncology
  • Consider Infectious Disease consult