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 Algorithm 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 Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR; InfectiousDiseases Society of America. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2011 Feb;52(4):e56-93. Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. Rosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother. 2014 Jul;58(7):3799-803. Cohen C, King A, Lin CP, Friedman GK, Monroe K, Kutny M. Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever And Neutropenia: Efficacy and Barriers. Pediatr Emerg Care. 2016 Nov;32(11):739-745. Lehrnbecher T, et al; International Pediatric Feverand Neutropenia Guideline Panel. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol. 2012 Dec;30(35):4427-38. Pathway Contacts Andrea Orsey, MD Natalie Bezler, MD Disclaimer 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. View all Clinical Pathways >
