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SUPPORTIVE CARE OF CHILDREN WITH CANCER: MANAGEMENT OF FEVER WITHOUT NEUTROPENIA

A.     Evaluation

Detailed history and physical examination

Bacterial cultures

a.     Obtain blood cultures from a venipuncture site and, for

patients with a central venous catheter, from each port

of the catheter.

b.     Obtain cultures of urine and other potential sites of

infection as indicated by history and physical examination (e.g., aspiration of cellulitis site or cerebrospinal

fluid if meningitis is suspected).

3.     Radiographs as indicated by history and physical examination

B.     Therapeutic measures

1.     When a central venous catheter is not present

a.     If a specific infection is not documented, continue to

examine daily and monitor clinically with daily blood

cultures and other relevant laboratory studies, but do

not start antibiotics.

b.     If a specific pathogen is isolated, treat with specific

antibiotics.

2.     When a central venous catheter is present

a. If only an exit-site infection is suspected, obtain blood cultures from all ports of the catheter, one venipuncture site (if practical), and the exit site.

i.     Begin antibiotic therapy with dicloxacillin 25

mg/kg/day PO divided q6h.

ii.     Re-examine at 24-48 hours.

iii.     If improved, finish 10-day course of antibiotic

therapy.

iv.     If not improved after 48 hours of dicloxacillin, commence therapy with vancomycin 40 mg/kg/day IV

divided q8h (maximum 2 g/day) and tobramycin or

gentamicin 6-7.5 mg/kg/day IV divided q8h.

v.     If not improved after 72 hours of parenteral therapy,

change antibiotics or consider removing the

catheter.

b.     If there is no evidence of local infection, obtain blood

cultures from all catheter ports and one venipuncture site. Many physicians would choose to commence parenteral therapy with ceftriaxone 50 mg/kg IV q24h.

c.     If the cultures are negative and the fever defervesces,

stop antibiotic therapy after 48 hours.

d.     If the cultures are positive, adjust antibiotic therapy

appropriately to sensitivity of the organisms. If cultures remain positive despite 48 hours of appropriate

antibiotic therapy, strongly consider removing the central venous line.

e.     If the cultures become negative, complete a 10- to 14-

day course of antibiotics and do not remove the

catheter.

*16\168\2*

Cancer



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