Oncology Patient with Fever Clinical Pathway — Emergency Department, Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Quality Story
Reducing Inpatient Hospital Days for Cancer Patients with Fever

Oncology Patient with Fever in the Outpatient Setting:
ED or Oncology Clinic

Triage

As clinically indicated:
- Sepsis Huddle
- Sepsis Pathway, ED, Inpatient and PICU

Antibiotic Recommendations for Special Patient Populations

Engineered Cell Therapy
(e.g., CART 19)
Avoid steroids
Stem Cell Transplant
(Includes BMT, PSCT)

FLOC/RN team assessment
- Push Provider Button if team not present
History, physical exam
- RN
  CVC or IV access, CBC, blood culture
- FLOC
  Oncology fever orders
  Order antibiotics
  Consider need for stress steroids
  Excluding engineered cell therapy patients
Complete History, Physical Exam
Further Diagnostic Studies

Review the Following for Choosing the Antibiotic
- Type of central venous catheter (CVC)
- Special population: SCT, BMT, CART
- Presence of GVHD
- Last ANC
- Vancomycin Indications
- Drug allergy
- MDRO tab
- Past 12 months of blood cultures

As clinically indicated: Sepsis ED Alert, Sepsis Huddle, ED Sepsis Pathway

Broviac or PICC

Port

No Line

Cefepime
+/- Vancomycin

If ANC < 200 in previous 24 hours, Review Low-Risk Criteria
If not Low Risk, give Cefepime instead of Ceftriaxone

Ceftriaxone

Check ANC

Oncology Consult (ED)
Admit

No Neutropenia

Neutropenia

No Neutropenia

Oncology Consult (ED)
Discharge

Ceftriaxone

Oncology Consult (ED)
Discharge

Assess Risk

LOW RISK

NOT LOW RISK

Rationale for Oral Antibiotic Treatment in Neutropenic Oncology Patients Identified as Low Risk

Outpatient Treatment:
Levofloxacin
Review criteria with
Oncology
ED/Clinic Discharge
Checklist
Ensure phone
follow-up 24 hours

Admit to Oncology Inpatient Antibiotic
Treatment Plan
Give Cefepime
+/- Vancomycin

Low-Risk Criteria for Discharge for Fever/Neutropenia in Oncology patients with Port or No Line

To be considered for discharge, the patient must:

Have no defined bacterial illness
Have no visible disruption of mucocutaneous barriers and
Expected period of neutropenia is ≤ 7 days

Low-risk Criteria: Clinical	Low-risk Criteria: Medical History	Low-risk Criteria: Social
Age > 6 months Tolerating PO, able to take enteral medications HPI/PE consistent with likely viral illness Reassuring physical exam, VS Low concern for focal, invasive bacterial or fungal conditions such as: Pneumonia Cellulitis Urinary tract infection	No history of: Current neutropenia expected to last ≥ 7 days in a patient with leukemia/lymphoma Relapse leukemia not in remission BMT within preceding 12 months Trisomy 21/Down Syndrome Currently receiving therapy for GVHD Received > 15 days of glucocorticoids in last 30 days Current use of broad-spectrum antibiotics Bacteremia within the last 30 days Any surgery in the preceding 2 weeks, excluding line placement VP shunt, Ommaya reservoir, or other implanted devices at present, excluding ports Engineered Cell Therapy within past 100 days	Family able to: Follow up in clinic in 24-72 hours Receive daily follow-up calls To fill Levofloxin prescription

Posted: February 2008
Revised: May 2022
Authors: Ku, B. MD; Reilly, A. MD; Jacobstein, C. MD; Lavelle, J. MD; Kersun, L. MD, Bailey, C. MD

Evidence

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us.

©2024 by Children's Hospital of Philadelphia, all rights reserved.
Use of this site is subject to the Terms of Use.

The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Emergency Department and Outpatient Specialty Care Clinical Pathway for Oncology Patient Presenting with Fever

Evidence