Febrile Pathway

Diagnosis of Febrile Neutropenia: Neutropenia: ANC < 500 cells/m3 or expected decrease to <500 cells/m3 during the next 48 hours AND : temperature >38

Labs: CBC with diff, CMP, Blood cultures Obtain 2 blood cultures at time of fever and with each subsequent fever. Perform complete Include 1 anaerobic culture bottle if concerned for anaerobic process physical exam but do Use central line for blood cultures when possible NOT perform rectal Other studies as clinically indicated: e.g. CXR, respiratory pathogen panel, exam stool studies, UA (no catheter specimens)

Additional : Empiric antibiotics: ADMINISTER ANTIBIOTICS When clinically indicated, First line: WITHIN 1 HOUR OF consider addition of an If concerned for intra-abdominal process: -tazobactam PRESENTATION: agent to cover resistant gram- If concerned for cefepime-resistant organism: DO NOT DELAY ANTIBIOTICS positive bacteria (e.g. Severe beta-lactam allergy: consult Infectious Diseases WHILE WAITING FOR LAB MRSA, coagulase-negative Concern for central nervous system : consult Infectious RESULTS staphylococcus, enterococcus). Diseases Options may include: Daptomycin, Ceftaroline, and IV fluid bolus(es) if indicated Vancomycin Re-evaluation at 48 hours of empiric therapy

Positive culture obtained or source identified?

NO YES

If previously started, consider discontinuation of extended grampositivecoverage (e.g. daptomycin / vancomycin / Consult Infectious cefaroline),even if patient remains febrile Diseases to Continue other agent(s) and close clinical assessment determine appropriate Consider ID consult definitive treatment course

Patient afebrile before 5 days

YES

NO YES Source identified?

Patient remains febrile for 5 days or more*: NO Initiate empiric antifungal treatment Call Infectious diseases to decide best choice, appropriate infection workup and if formal consult needed

Continue empiric antibiotics until ANC >200 and rising AND patient *Also applies if fever resolves and then recurs while on afebrile AND well-appearing antibiotics for 5 continuous days