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Fever and neutropenia is a common complication of the treatment of cancer. The risk of serious bacterial infection is related to the degree and duration of neutropenia. Bacteraemia is diagnosed in up to one-third of children with FN.
A single temperature ≥ 38.5°C or a sustained temperature ≥ 38.0°C over 1 hour.
An absolute neutrophil count < 500/mm3 OR < 1000/mm3 with predicted decline to < 500/mm3 over the next 48 hours
Neutropenia should be suspected in any oncology patient that has received chemotherapy (oral or intravenous) within the last 14 days and other children with recurrent neutropenia.
High risk cancer treatment protocols
Acute myeloid leukaemia (AML) treatment; Acute lymphoblastic leukaemia (ALL) induction, ALL delayed intensification, infant ALL; lymphoma induction; allogeneic transplant (day-14 to day+356); autologous transplant (day-7 to day +30); re-induction chemotherapy for any relapse.
Fluid bolus or inotrope requirement, need for any respiratory support and/or altered conscious state
Primary Treatment Centre
The centre where the patient was diagnosed and the treatment plan decided. For the majority of children this will be either Royal Children's Hospital or Monash Children's Hospital.
Initial treatment algorithm
Request to see patient's Febrile Neutropenia Treatment Card or Letter. This will have important information regarding cancer diagnosis, risk status and recommended antibiotics
History and examination with particular attention to:
Patients who are clinically stable
Piperacillin-tazobactam* 100mg/kg (max 4g) iv 6H
Non-life threatening penicillin hypersensitivity (rash):Cefepime 50mg/kg (max 2g) iv 8H (preferred)OR Ceftazidime** 50mg/kg (max 2g) iv 8H
Life-threatening (immediate) penicillin or beta-lactam hypersensitivity:Ciprofloxacin 10mg/kg (max 400mg) iv 12HAND Vancomycin 15 mg/kg (max 500 mg) iv 6H (target trough 10-15 mg/L pre 5th dose)
Patients who have any of:
(i) Systemic compromise/sepsis(ii) High risk cancer treatment (ii) Inpatient onset FN
As for patients who are clinically stableAND Amikacin*** 22.5 mg/kg (18 mg/kg if >10y) (max 1.5 g) iv 24H (Target trough <2mg/L pre 3rd dose)
Regional centres may choose alternate aminoglycoside (i.e. gentamicin) depending on local susceptibility data
Patients with suspected resistant Gram-positive infection
(Including patients with cellulitis, obviously infected vascular devices, proven Gram-positive bacteraemia, and known MRSA colonisation with extensive skin breaks)
As for patients who are clinically stableAND vancomycin 15 mg/kg (max 500 mg) iv 6H (target trough 10-15 mg/L pre 5th dose)
Cease if susceptibilities indicate an alternative agent can be used
NB. Prolonged fever in a clinically stable patient is NOT an indication to commence vancomycin
Patients with features of abdominal or perineal infection
As for patients who are clinically stableAND metronidazole 7.5mg/kg (max 500mg) iv/oral 8H if receiving cefepime, ceftazidime or ciprofloxacin as first line antibiotic
NB. Piperacillin-tazobactam will provide adequate anaerobic cover, other than for suspected Clostridium difficile colitis
* Trade names for piperacillin-tazobactam include Tazocin®, Tazopip®, PiperTaz®, and DBL Piperacillin and Tazobactam®. Doses refer to piperacillin component.
** Ceftazidime has reduced activity against viridans group streptococci. It should be avoided in patients with extensive mucositis, recent high dose methotrexate or cytarabine and ciprofloxacin prophylaxis.
*** IV aminoglycoside antibiotics (i.e. amikacin and gentamicin) should not be given simultaneously through the same line as IV penicillins including piperacillin-tazobactam and ticarcillin-clavulanate. The line should be flushed well with sodium chloride 0.9%, before and after giving each medication.
If patient has signs of sepsis:
After the first dose of antibiotic has been given, complete the following:
A full examination with particular attention to:
Additional investigations as indicated:
Consider transfer to the patient's Primary Treatment Centre (PTC) if:
Transfer should be discussed with the oncology consultant/fellow at the patient's primary treatment centre (see contact details below). For further advice and to arrange inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007
Patients should undergo daily:
After 24-48 hours, discontinue Amikacin and/or Vancomycin (if initiated) unless
Do not broaden initial empiric antibiotic regimen based solely on persistent fever in children who are clinically stable
All treatment modifications, including cessation of antibiotics, should be discussed with the patient's primary oncology team.
All treatment modifications, including cessation of antibiotics, should be discussed with the patient's primary oncology team
Evaluation for IFI
Empiric treatment for suspected IFI