Clinical Pathway for Oncology Patient Presenting with Fever

Treatment for Special Patient Populations

Triage
Consider need for Sepsis Huddle

RN/MD/CRNP Rapid Assessment

Order Antibiotics or
Push Provider Button if team not available

RN Line access, CBC, Blood Culture
MD/CRNP Order Antibiotics, CBC, Blood Culture
Consider need for stress dose steroids, excluding Engineered Cell Therapy patients

Complete History, Physical Examination
Further Diagnostic Testing

 

 
Ill Patient
Regardless of central venous catheter type
Broviac or PICC
Port
Ceftriaxone
No Line
  • 1. Cefepime
  • 2. Vancomycin
  • 3. Gentamicin
ED Sepsis Pathway
as clinically indicated
Oncology Consult
(ED patients)
Admit
  • 1. Cefepime
  • 2. Gentamicin
  • 3. +/- Vancomycin
Oncology Consult
(ED patients)
Admit
No Neutropenia
Neutropenia
Neutropenia
No Neutropenia
Oncology Consult
Ceftriaxone
Oncology Consult
No antibiotics
Discharge
Assess Risk
Discharge
LOW RISK
NOT LOW RISK

To be considered for discharge, the patient must:

  • Have no defined bacterial illness
  • Have no visible disruption of mucocutaneous barriers, AND
  • The expected period of neutropenia is ≤ 7 days

The patient must also meet all other low-risk criteria:

Low-risk Criteria: Clinical
  • Age > 6 months
  • Tolerating PO, able to take enteral medications
  • HPE 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
Low-risk Criteria: Medical History
  • No history of:
  • Prolonged neutropenia ≥ 7 days in a patient with leukemia/lymphoma
  • Relapse leukemia with active disease
  • Trisomy 21
  • BMT within preceding 12 months
  • Currently receiving therapy for GVHD
  • Received > 15 days of glucocorticoids in last 30 days
  • Current use of broad-spectrum antibiotics
  • Any surgery in the preceding 2 weeks, excluding line placement
  • VP shunt, Ommaya reservoir, or other implanted devices at present, excluding ports
  • Current Engineered Cell Therapy therapy patients (history of engineered cell therapy infusion)

Low-risk Criteria: Social

  • Family able to:
  • Follow up in clinic in 24-72 hours
  • Receive daily follow-up calls
  • To fill Levofloxin prescription
Posted: February 2008
Revised: November 2011, December 2012, January 2014, March 2014, December 2014, March 2015, March 2017, May 2018, June 2019
Authors: Ku, B. MD; Reilly, A. MD; Jacobstein, C. MD; Lavelle, J. MD; Kersun, L. MD, Bailey, C. MD