ED Pathway for the Evaluation/Treatment of the Oncology Patient with Fever

Choosing the Antibiotics

Review the following information to choose antibiotic therapy:
Presence, type of central line Port vs. Broviac
Time elapsed since BMT > or ≤ 6 months
Active GVHD Presence of active GVHD on immunosuppressive therapy (regardless of time since BMT)
ANC Well-appearing patients with an ANC > 500 are candidates for ceftriaxone and discharge after discussion with Oncology consultant if NONE of the following are present:
Broviac line
Recent BMT < 6 months ago
BMT with active GVHD
PCN Allergy Allergy defined as:
Anaphylaxis to PCN OR
History of ANY cephalosporin reaction
Replace cefepime with aztreonam, clindamycin
In BMT pts, replace with aztreonam, vancomycin
Indications for addition of vancomycin Ill patients
History of MRSA
AML
Relapsed ALL
BMT < 6 months with any central line
History of VRE Discuss with Oncology consultant
Empiric coverage is no longer recommended
Consider empiric coverage with linezolid in patients who are unstable
History of infection with resistant or unusual organism Especially extended spectrum beta lactamase organisms
Discuss with Oncology consultant, Infectious Disease

Important Facts about Antibiotic Therapy

Medication Dose (mg/kg) Maximum Dose Infusion/Flush Time Indications
Cefepime 50 2 grams 30 min  
Vancomycin
Patients w/o BMT 15
BMT Patients 10
500 mg 1 hour Ill Patients
History of :
MRSA
AML
Relapsed ALL
Gentamicin
Stable Patients <1 yr 2.5
≥1 yr 7
Unstable patients and
all BMT patients
2.5
none 30 min  
Ciprofloxacin 10 400 mg 1 hour
Ceftriaxone 75 2 grams 30 min  
Linezolid
<12 yrs 10 mg/kg
≥12 yrs 600 mg
600 mg 30 min Ill pts w/history of VRE