D ecisi on Tree for : Medical Solid Tumour and Lymphoma Patients

Defined as Temperature greaterFev er than an ord Neutropenequal to 38 degressia and Absolute Count less than 0.5 or less than 1 and expected to decrese to less than 0.5

In it ial E v al ua ti o n

LowLow RiskR isk High Risk (Appendix(Appendix 1)1)

Ciprofloxacin 750 mg PO q 12 h + Amoxicillin- No defined focus DefinedDefine focus Focus C ipr of loClavulanatexaci n 7 50 500 mg mgpo PO q1 q 2h8 h. + A mox ici ll in - http://www.lhsc.on.ca/priv/sepsis/campaign.htm If penicillinC ,lavul an ciprofloxacinat e 500 m750g po mg q8 POh. If pe ni cil linq a 12ller h gasy ,monotherapy. ens u r e an ti b iotics pr o vi d e Ensure provide optimal optima l th er(Appendixapy for f ocus,2) whil e a lso No penicillin allergy Penicillin allergy for focus, while also m a in taini n g gram-negati ve cover a g e . maint ai n ing gr am-negati v e ( A ppendi x 2 , Appendix 3) coverage. Ceftazidime 1 g IV q 8 h +/- C(fore f increasedtaz idi me 1ggramq8 h IV q8h CiprofloxacinCiprofloxacin 400 400 mg mg IVIV qq12h 12 h + + Vancomycin Vancomycin 1g 1 IV g IV positive coverage) or Pipercillin/Tazobactam(Appendix 4.5 g IV q3) 6 h or qq12h 12 h (this(this regimen regimen not not recommended recommended if receivingif receiving imipenem-cilastatin 500 mg IV q 6 h. Initiate+/ - vancomycinVancomycin under(Appendix 3 , prophylaprophylacticct fluoroquinolone.ic flu o roquinolone. Choose Ch alternativeoose alternative Duration specific for focus, S&S the conditions outlined in AppendixAppendix 4 5) . gram-negativegram-negative coverage) coverage)(Appendix(Appendix 2) (Appendix 2) 3) resolved. Until afebrile 5 to 7 days, ANC greater than and equal to 0.5 x 10 9 cells/L. Monitor, reassess. ReassessR eas sess after aft 72er hours, 72 hour or sooners, or ifso indicated,on er if i n dicated, basedbase don on C&SC&S and an clinicald c lini S&Sca (Appendixl S&S (Appendix 3) 4)

Afebrile forgreater greater than than and or equal equal to to 48 48 hours hours Febrile

ANC greater than and equal to 0.5 x 10 cells/L 99 ANCANC greater greater than andor equal equal to 0.5 x x 10 10 cells/L 9 cells/L ANC greater than or equal to 0.5 x 10 cells/L ANC less than 0.5 x 10 9 cells/L ANC less than 0.5 x 10 9 cells/L forgreater greater than than and or equal equal to to48 48 hours hours for greatergreater than than and or equal equal to to 5 5days days D isc on tinue a n tibiotics if c linically well, no fo cu s of in fe ction an dcul tures ReReassessas sess (A(Appendixpp endix 4)3) Initally low risk Initially high risk ne gati ve . Monit or, reassess. D isc ont inue antibiot ic s i f c lin ica lly w e ll, no focus of in fection and cultu r es Dis c ontinu e an tibio tics ContinueContinue antibiotics until until Condition stable Condi tion worsens, and new Condition worsens and no neg at ive. M o n itor , when afebrile 5 to 7 ANC greatergreater than than and or equalequal focus identified new focus identified rea s sess. days if no complications. toto 0.5 0.5 xx 10 cells/L9 cells/L Monitor, reassess. oror for for 2 2 weeksweeks total therapy. therapy. Contin ue a ntibiotics Monitor, reassess. fo r 2 weeks Monitor, reassess. Change antibiotics per C&S/ ConsiderConsult empiric Infectious antifungal Diseases if still Servicefebrile ifafter available 7 days. or Consulttransfer to S&S while also mainta in in g In fec tio us D iseases Se rvice i f Mo nitor, reassess gram-negative coverage available,closest ortertiary transfer facility. to closest May consider empirictertiary antifungal facility. if still febrile after 4 days. Monitor, reassess

DISCLAIMER The London Health Sciences Centre (LHSC) and London Regional Program (LRCP) developed these guidelines for the purpose of assisting medical practitioners in the treatment of febrile neutropenic patients undergoing cancer . They apply only to solid tumours and lymphoma. They apply to inpatient management only. These guidelines are general and the application must consider the variations in individual patients, types of being treated, antimicrobial susceptibility patterns, underlying causes of neutropenia, and expected time to recovery. It must be noted that no specific scheme, no specific drug or combination, and no specific period of treatment can be applied unequivocally to all patients with neutropenia and . LHSC will not assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information in this document.

Updated November 2014 Appendix 1 Appendix 3 Factors Favoring Low-Risk for Severe in Febrile Neutropenia in Fever persisting more than 3 days and in whom no source or Patient with Solid Tumors (non-hematological malignancies organism has been identified is suggestive of a non-bacterial ADULT ONCOLOGY x Adjuvant Treatment infection, a bacterial infection resistant to the (s) FEBRILE NEUTROPENIA PREPRINTED ORDERS x Expected duration neutropenia of less than7 days emergence of a second infection, inadequate serum and tissue

KEY: R - REQUISITIONED P - PROCESSED (KARDEX) x ANC greater than or equal to 1 levels of antibiotic, drug fever, cell wall-deficient bacteremia or NON-MEDICATION ORDERS RP MEDICATION ORDERS P x Non hematologic cancer infection at an avascular site, such as or catheter.

Reason for Exam / Clinical History and Contact # required for all  Start IV Sodium Chloride 0.9% at ______mL/hour Some patients with microbiologically defined bacterial / Nuclear orders. x No prior infection x No obvious focus of infection infections may, however, require more than 5 days of UPON PATIENT ARRIVAL therapy before defervescence occurs. x No MONITORING / VITAL SIGNS:  ANTIBIOTICS: Reassessment should include:  x No confusion BP: Supine and Sitting/Standing, Temperature, ______HR, RR, SpO2 x Review of all previous culture results ______x No diarrhea or vomiting  Weight: ______kg x A meticulous physical examination ______x Grade 2 mucositis or less INVESTIGATIONS: ______x Chest x-ray  x Compliant (needs to come in if diarrhea or vomiting or can’t take oral meds) CBC, Diff, Electrolytes, Urea, Creatinine STAT, x Status of all vascular catheters Glucose (random) x Normal organ function (renal, hepatic, pulmonary, cardiac)  INR, PTT x Additional cultures  Acetaminophen ______mg PO q ______hours PRN  Group and Reserve x No diabetes temperature greater than or equal to 38°C x Specimens of specific sites of infection  Peripheral blood culture x 2 sets 30 to 60 minutes x Does not live alone (friend or family member at home until neutropenia apart. If central line, take both peripheral and x Diagnostic imaging of any organ suspected of having central at same time. resolved)  infection Urine C & S x Access to medical care (less than 1 hour) and initial daily medical outpatient  Culture other sites as indicated x If possible, serum concentrations of antibiotics, especially  Notify MD On Call of significant findings x Follow-up especially re culture results  Chest X-Ray PA Lateral: aminoglycosides Indication febrile neutropenia  AST, ALT, Total Bilirubin

AFTER INITIAL ASSESSMENT MONITORING / VITAL SIGNS:  Appendix 2 Temperature, HR, RR, BP, SpO2 q 4 hours, Appendix 4 reassess at 48 hours Antibiotics requiring dose Adjustments in Patients Vancomycin Use  Intake and output  Activity as tolerated with Renal Dysfunction There are some instances when Vancomycin should be initiated immediately. These are: LABORATORY:  Daily CBC, Diff, Electrolytes, Urea x Ceftazidine Hemodynamic instability or other evidence of severe sepsis  x Serum Creatinine x 48 hours, then reassess x Vancomycin  x Pneumonia documented radiograhically Other bloodwork: ______x Ciprofloxacin x Positive blood culture for gram-positive , before final identification and DIET: x Amoxicillin/Clavulanate  Regular susceptibility testing is available x /Tazobactam  Other: ______x Clinically suspected serious catheter related infection (e.g. chills or rigors with

PRESCRIBER’S DATE x Imipenem-cilastatin infusion through catheter and cellulitis around the catheter entry/exit site) PRINTED NAME / SIGNATURE / CONTACT #: (YYYY/MM/DD): TIME: PROCESSOR’S DATE NURSE DATE Readily accessible resources to consult when determining INITIALS: (YYYY/MM/DD): TIME: INITIALS: (YYYY/MM/DD): TIME: x Skin or soft-tissue infection at any site NS3074 (Rev. 2012/07/17) DISTRIBUTION: WHITE - Patient’s Chart CANARY - PINK - Nurse dose reductions include the CPS, Micromedex and x Colonization with MRSA or -resistant Streptococcus pneumonia Lexicomp x Severe mucositis, if fluoroquinolone prophylaxis has been given and Ceftazidine is employed as empirical therapy