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Oncology Patient with Fever

Pathway Background and Objectives

Cancer patients undergoing chemotherapy are at high risk of infection due to a multitude of factors including their underlying disease process, the presence of central lines, and chemotherapy induced neutropenia and immunosuppression. Infection is subsequently a major cause of morbidity and mortality in this population. Often, the first sign of a potential infection is fever, and febrile events occur in approximately 1/3rd of cancer patients with neutropenia. Early antibiotic administration has been associated with higher survival rates. In an effort to improve rapid evaluation and administration of antibiotics, standardized protocols have been shown to improve outcomes. Broad-spectrum antibiotics are routinely given to cover for gram-positive and gram-negative organisms. Due to the increased practice of prophylactic antimicrobials and the use of central lines, there has been a shift towards a dominance of gram-positive bacteremia, including methicillin resistant staphylococcus aureus (MRSA). As a result, early vancomycin treatment may reduce mortality in high risk patients. However, judicious use of these antibiotics is warranted as there has been a link between their overuse and the development of drug resistant organisms.

The objectives of this pathway are to:

  • Decrease time to antibiotics
  • Decrease morbidity/mortality from infection
  • Improve rate of correct antibiotic coverage for neutropenic oncology patients with different risk factors
  • Decrease unnecessary long-term antibiotic use and associated toxicities
  • Increase rate of proper anti-fungal coverage
  • Decrease unnecessary admissions for low risk patients


Download Oncology Patient with Fever Pathway Algorithm Updated April 26, 2021

Attention: There is currently a shortage of intravenous (IV) clindamycin

In the event of a shortage at your institution, Connecticut Children’s Infectious Diseases and Immunology and Antimicrobial Stewardship Program suggest the following alternatives:

  • If your patient is able to effectively take oral medications, it is recommended to simply substitute with oral clindamycin at a similar dose, as oral clindamycin has very high bioavailability (i.e., > 90%).
  • If being used due to a penicillin allergy in a standard risk patient:
    • If patient can tolerate cephalosporins: cefepime (+ metronidazole if concerns for typhlitis)
    • If patient is unable to tolerate cephalosporins: vancomycin or linezolid in combination with ciprofloxacin (+ metronidazole if concerns for typhlitis)

If you have any questions on further alternatives or appropriateness of antibiotics, please call our Infectious Diseases and Immunology Department through the One Call Hotline at 1-833-PEDS-NOW to be connected with the On-Call physician.

Quality Metrics

  • Percentage of patients with pathway order set usage
  • Average time from arrival (or start of fever) to initial antibiotic order
  • Average time from antibiotic order to antibiotics administration
  • Average time from arrival (or start of fever) to antibiotic administration
  • Percentage of patients who received the correct initial antibiotic regimen as indicated per pathway
  • Percentage of patients that are appropriately changed from Ceftazidime to Piperacillin/Tazobactam once Vancomycin is discontinued

Educational Module

Download Oncology Patient with Fever Educational Module Updated April 26, 2021

Key References

Pathway Contacts

  • Andrea Orsey, MD
  • Natalie Bezler, MD


The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.

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