Emergency Department and Outpatient Specialty Care Clinical Pathway for Oncology Patient Presenting with Fever
- As clinically indicated:
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
- RN
- 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
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
If not Low Risk, give Cefepime instead of Ceftriaxone
Ceftriaxone
Oncology Consult (ED)
Admit
Admit
No Neutropenia
Neutropenia
Neutropenia
No Neutropenia
Oncology Consult (ED)
Discharge
Discharge
Ceftriaxone
Oncology Consult (ED)
Discharge
Discharge
Assess Risk
LOW RISK
NOT 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 |
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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
Revised: May 2022
Authors: Ku, B. MD; Reilly, A. MD; Jacobstein, C. MD; Lavelle, J. MD; Kersun, L. MD, Bailey, C. MD
Evidence
- CEP Evidence Review
- Guideline for the Management of Fever and Neutropenia in Children With Cancer and/or Undergoing Hematopoietic Stem-Cell Transplantation
- Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update
- Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America
- Prevention and Treatment of Cancer-related Infections, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology.