Emergency Department and Outpatient Specialty Care Clinical Pathway for Oncology Patient Presenting with Fever

Antibiotic Recommendations for Special Patient Populations
  • 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
  • Complete History, Physical Exam
  • Further Diagnostic Studies
Broviac or PICC
Port
No Line
If ANC < 200 in previous 24 hours, Review Low-Risk Criteria
If not Low Risk, give Cefepime instead of Ceftriaxone
Ceftriaxone
Oncology Consult (ED)
Admit
No Neutropenia
Neutropenia
Neutropenia
No Neutropenia
Oncology Consult (ED)
Discharge
Ceftriaxone
Oncology Consult (ED)
Discharge
Assess Risk
LOW RISK
NOT LOW RISK
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
  • Age > 6 months
  • Tolerating PO, able to take enteral medications
  • HPI/PE 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
  • No history of:
  • Current neutropenia expected to last ≥ 7 days in a patient with leukemia/lymphoma
  • Relapse leukemia not in remission
  • BMT within preceding 12 months
  • Trisomy 21/Down Syndrome
  • Currently receiving therapy for GVHD
  • Received > 15 days of glucocorticoids in last 30 days
  • Current use of broad-spectrum antibiotics
  • Bacteremia within the last 30 days
  • Any surgery in the preceding 2 weeks, excluding line placement
  • VP shunt, Ommaya reservoir, or other implanted devices at present, excluding ports
  • Engineered Cell Therapy within past 100 days
  • Family able to:
  • Follow up in clinic in 24-72 hours
  • Receive daily follow-up calls
  • To fill Levofloxin prescription
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