Fever - Oncology patient

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To guide Emergency Department (ED) staff in the assessment and management of oncology patients who present with fever.

Risk

Oncology patients undergoing chemotherapy are immunosuppressed and at risk of sepsis. Early recognition and treatment is essential in these patients.

Key points 

• The Oncology ward will provide a Patient Summary Sheet for expected patients who will be presenting to the ED. This will be entered in the Digital Medical Record (DMR) and summarises patient diagnosis, allergies, alerts, treatment regimen, Central Venous Access Device (CVAD) details and a recent weight.
• On completion of the initial medical assessment, the on call Oncology Fellow / Oncologist and Emergency Consultant / Night Medical Team leader must be notified immediately of all febrile oncology patients.
  •  The Senior ED doctor (Consultant or Registrar) is to chart on the paediatric Hospital Medication Chart (pHMC):
    • IV Cefepime 50 mg/kg/dose (to a maximum of 2 g)
      8 hourly^1,5, (subject to patient allergies and unless otherwise identified within the patient summary) based on recent weight. Ideally, this will be done before patient arrival to ED.
• First dose of antibiotics must be administered within 60 minutes of the patient's arrival in ED.^1-4
  • Senior ED doctor (Consultant or Registrar) to chart on the paediatric National Inpatient Medication Chart (pNIMC): IV Cefepime 50mg/kg/dose (to a maximum of 2g) 8 hourly^1,5, (subject to patient allergies and unless otherwise identified within the patient summary) based on recent weight, ideally before patient arrival.
• Do not access an infusaport if inserted within last 5 days (unless under instruction of oncologist). 
• HiTH patients on the Low-Risk Febrile Neutropenia Pathway within the Identification and management of children with cancer and low-risk febrile neutropenia guideline (internal WA health only) presenting to ED for medical review will present with a re-admission letter. These patients will generally be on a cefepime continuous infusion.
• For patients with signs of sepsis, additional antibiotics (vancomycin and gentamicin) should be administered as outlined below. Discuss ongoing antibiotics with the oncology team. Refer to the Paediatric Sepsis Pathway.

Initial management of Fever in Oncology Patient

PCH ED pathway

*Antibiotics

• Dosing as per ChAMP guideline: Fever in the Oncology patient (or non-oncology neutropenia) (ChAMP).
• IV Cefepime 50 mg/kg/dose (to a maximum of 2 g) 8 hourly⁵
  • (Some patients require antibiotics other than cefepime - refer to patient notes and Oncology Fellow on call).
• If haemodynamically unstable add:
  • IV Vancomycin 15 mg/kg/dose (to a maximum of 750 mg) 6 hourly⁵
    and
  • IV Gentamicin: 
    ≥4 weeks to 10 years 7.5 mg/kg/dose (to a maximum of 320 mg) as a single dose⁵
    >10 years to 18 years 6-7 mg/kg/dose (to a maximum of 560 mg) as a single dose⁵
• Should be charted by doctor as soon as patient weight is known (pre-arrival or post weighing in ED).

** Oncology referral checklist

1. Current observations and stability
2. Result of venous blood gas, including lactate 
3. Antibiotics administered
4. Possible source of infection
5. Maintenance fluids charted on Parenteral Fluid Therapy Order Chart (MR828) if patient has been administered vancomycin in ED.
6. Need for future investigation such as chest x-Ray, viral studies, CVAD exit line swabs, urine and stool culture

Useful resources

1. Cruz AT, lane RD, Balamuth F et al. Updates on Paediatric Sepsis. JACEP (open access). 2020; 1:981 – 993. 
2. Children’s Health Queensland Hospital and Health Service. Management of fever in a paediatric oncology patient Guideline, 2020.
3. Fletcher M, Hodgkiss H, Zhang S, Browning R, Hadden C, Hoffman T, Winick N, McCavit TL. Prompt administration of antibiotics is associated with improved outcomes in febrile neutropenia in children with cancer. Pediatr Blood Cancer. 2013 Aug;60(8):1299-306. doi: 10.1002/pbc.24485. Epub 2013 Feb 15. PMID: 23417978.
4. Critical Care Medicine. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
5. Australian Medicines Handbook (AMH) Children’s Dosing Companion. Updated January 2021. 

Endorsed by:	Drugs and Therapeutics Committee	Date:	Jan 2025
		Review date:	Apr 2028

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