Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients

Publication Date: January 23, 2023
Last Updated: January 31, 2023

SECTION A: INITIAL PRESENTATION OF FN

Initial Management: Risk Stratification
  • A1. Adopt a validated risk stratification strategy and incorporate it into routine clinical management (strong recommendation, low-quality evidence).

Initial Management: Evaluation
  • A2. Obtain blood cultures at the onset of FN from all lumens of central venous catheters (strong recommendation, low-quality evidence).
  • A3. Consider obtaining peripheral blood cultures concurrent with central venous catheter cultures (conditional recommendation, moderate-quality evidence).
  • A4. Consider urinalysis and urine culture in patients where a clean-catch, mid-stream specimen is readily available (conditional recommendation, low-quality evidence).
  • A5. Obtain chest radiography only in patients with respiratory signs or symptoms (strong recommendation, moderate-quality evidence).

Initial Management: Treatment
  • A6. In high-risk FN
    • A6a. Use monotherapy with an antipseudomonal β-lactam, a fourth-generation cephalosporin or a carbapenem as empiric antibacterial therapy in pediatric high-risk FN (strong recommendation, high-quality evidence).
    • A6b. Reserve addition of a second anti-Gram-negative agent or a glycopeptide for patients who are clinically unstable, when a resistant infection is suspected, or for centers with a high rate of resistant pathogens (strong recommendation, moderate-quality evidence).
  • A7. In low-risk FN
    • A7a. Consider initial or step-down outpatient management if the infrastructure is in place to ensure careful monitoring and follow-up (conditional recommendation, moderate-quality evidence).
    • A7b. Consider oral antibacterial therapy administration if the patient is able to tolerate this route of administration reliably (conditional recommendation, moderate-quality evidence).

SECTION B: ONGOING MANAGEMENT OF FN EXCLUDING EMPIRIC ANTIFUNGAL THERAPY

Ongoing Management: Modification of Treatment
  • B1. In patients who are responding to initial empiric antibacterial therapy, discontinue double coverage for Gram-negative infection or empiric glycopeptide (if initiated) after 24-72 hours if there is no specific microbiologic indication to continue combination therapy (strong recommendation, moderate-quality evidence).
  • B2. Do not broaden the initial empiric antibacterial regimen based solely on persistent fever in patients who are clinically stable (strong recommendation, low-quality evidence).
  • B3. In patients with persistent fever who become clinically unstable, escalate the initial empiric antibacterial regimen to include coverage for resistant Gram-negative, Gram-positive and anaerobic bacteria (strong recommendation, very-low-quality evidence).
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​​​​​​​Ongoing Management: Cessation of Treatment
  • B4. In both high-risk and low-risk FN patients who have been clinically well and afebrile for at least 24 hours, discontinue empiric antibacterial therapy if blood cultures remain negative at 48 hours if there is evidence of marrow recovery (strong recommendation, low-quality evidence).
  • B5. In patients with low-risk FN who have been clinically well and afebrile for at least 24 hours, consider discontinuation of empiric antibacterial therapy if blood cultures remain negative at 48 hours despite no evidence of marrow recovery (conditional recommendation, moderate-quality evidence)

Overview

Title

Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients

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