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Management of Fever and Neutropenia - Pediatric Algorithms

Management of Fever and Neutropenia - Pediatric Algorithms - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Oncology, Related


Is the patient clinically
stable?
A,B
Emergency care, fluid resuscitation,
blood culture(s)
C
, CBC with Diff
Admit to
inpatient, See
Figure 2
Draw blood
culture(s)
C
and
CBC with Diff
Administer one dose of
ceftriaxone
D
in less
than 1 hour
E,F
Is the patient
neutropenic?
Ongoing
management
per provider
From: Management of Fever and Neutropenia – Pediatric – Inpatient/Ambulatory/Emergency Department –
Clinical Practice Guideline
Last Reviewed 6/2017; Last Updated 6/2017
Contact: Erin McCreary, PharmD, BCPS; emccreary@uwhealth.org
Figure 1. Empiric treatment of children with fever and possible neutropenia presenting to the Emergency Department
regardless of risk status; Empiric and ongoing treatment of low-risk children with fever and neutropenia
No
Yes
No
Is the patient
low-risk?
See Figure 2 for
treatment of
high-risk
children with
fever and
neutropenia
Can the patient take
medication orally?
Continue
ceftriaxone and
admit for
observation
Consider discharge within 48 hours
without antibiotics if afebrile
≥ 24 hours, culture negative, and
clinically stable, irrespective of marrow
status
IgE-mediated allergy or
severe reaction to β-
lactam?
Discharge with
levofloxacin for
2-4 days
Yes
Discharge with
ciprofloxacin plus
amoxicillin-clavulanate
therapy for 2-4 days
A
Fever is defined by any temperature ≥ 38°C. Discuss
case with Pediatric Heme/Onc Fellow/Attending and
call the PICU as soon as possible. Neutropenia
defined as ANC <500.
B
Patients with suspicion for neutropenia should never
have a rectal temperature checked or receive a rectal
medication. NSAIDS should be avoided in all oncology
patients.
C
Culture all lumens of central line; peripheral culture not
required. Empiric antibiotic administration should
never be delayed to obtain culture data. All initial
antibiotics should be ordered “STAT” and administered
within one hour.
D
Consider aztreonam plus vancomycin if IgE-mediated
allergy or severe reaction to β-lactam
E
Do not wait for lab results to start antibiotics
F
Check vital signs every 15 minutes
Yes
No
Yes
No
Yes
No
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

From: Management of Fever and Neutropenia – Pediatric – Inpatient/Ambulatory/Emergency Department –
Clinical Practice Guideline
Last Reviewed 6/2017; Last Updated 6/2017
Contact: Erin McCreary, PharmD, BCPS; emccreary@uwhealth.org
Figure 2. Empiric treatment of high-risk children with fever and neutropenia
Does the patient meet criteria for
high-risk neutropenia and/or is the
patient clinically unstable?
Use Figure 1: Low risk or non-
neutropenic
IgE-mediated allergy or severe
reaction to β-lactam?
No
Start Aztreonam and Vancomycin
Start Cefepime
History of MDRO?
Clinically
Unstable?
Indication for vancomycin?
F
Suspicion for anaerobes or
abdominal source?
Change to
meropenem
Add tobramycin
and vancomycin
Add vancomycin
Add metronidazole
(or change to piperacillin-
tazobactam if no
β-lactam allergy or reaction)
No
Yes
Yes
F
Should add vancomycin:
Acute myeloid leukemia
Clinically unstable
History of methicillin-resistant
Staphylococcus aureus
History of β-lactam-resistant
Streptococcus spp.
Received high-dose cytarabine
F
Consider adding vancomycin:
Catheter-related infection
Grade 3 or 4 mucositis
Hospital-acquired pneumonia
Skin and soft-tissue infection
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org