1. Initial Management of Fever or Suspected Infection In Paediatric Oncology and Stem Cell Transplantation Patients Clinical Practice Guideline 1 st edition

2. Session Outline Aim and Background of the guideline Scope of the guideline Key Points in Recognition of infection in paediatric oncology and stem cell transplantation patients Assessment and Management Algorithm Antibiotic administration Supportive care interventions Summary Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

3. Aim of the Guideline The aim of this guideline is to ensure that paediatric oncology patients (including patients undergoing immunosuppressive Stem Cell Transplantation) at risk of infection receive appropriate treatment(Administration of antibiotics+ appropriate supportive care) within 60 minutes or less of presentation to any NSW health care facility. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

4. Background Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

5. Background Patients undergoing chemotherapy for cancer or SCT are at significant risk of infection, sepsis and potentially death. Clinical assessment and judgement of patients at presentation may not, with complete accuracy, discriminate those with and without significant infection. Prompt administration of antibiotics is the key to reducing morbidity and mortality. This guideline is aimed at the need to have antibiotics administered within 60 minutes of presentation to health care facility. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

6. Scope of the Guideline This clinical practice guideline is designed to provide assistance in the management in the initial 60 minutes of presentation to the health care facility of the following patients presenting with fever or reported fever > 38 0 C or who are unwell : – Patients on treatment for cancer – Patients who ceased treatment for cancer within the last 3 months – Recipients of Stem Cell Transplantation (SCT) within the last 12 or on immunosuppressive therapy – Oncology or SCT patients with Central Venous Access Device(CVAD) in situ Parental concern and judgment are extremely important and are valid triggers for following this clinical practice guideline irrespective of the child’s clinical condition. Decisions regarding subsequent changes to and duration of antibiotic therapy are beyond the scope of this guideline and are the responsibility of the treating oncologist Treating staff are expected to make contact with primary oncologist after starting initial treatment Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

7. Key Points in Recognition Fever and Neutropenia: In the literature different definitions of fever are used clinically and in paediatric febrile neutropenia research settings. For the purpose of this guideline the working party has agreed to the following definitions of fever and neutropenia: o Fever - a single temperature >38.0 O C by any route (axillary, oral, at home or on presentation) o Neutropenia - a Neutrophil count <1.0 x 10 9 /L (= 1000/mm 3 ) Neutropenic patients may not show usual signs of infection or inflammation Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

8. Key Points in Recognition Fever may be the only sign of infection in this group of patients Fever may be absent in some patients with significant infection Some patients may present with hypothermia Some patients may present with complaints like abdominal pain, diarrhoea, redness along CVAD, fainting in the absence of fever Central Venous Access Device (CVAD) with or without neutropenia can be a significant source of infection After accessing the CVAD and administration of antibiotics there may be acute deterioration due to septic shower/endotoxin release. It is vital that the child is closely observed and monitored for deterioration. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

9. Assessment and Management Urgent Triage, at least category 2 OR RAPID RESPONSE as per local CERS Prompt assessment to look for signs of toxicity Record observations on SPOC/PEDOC Classify patient (clinically stable, clinically unstable, severe sepsis/shock) and start treatment according to the algorithm Access CVAD or insert peripheral IV (Do not wait for topical anaesthetic to take effect) Collect blood culture, FBC, VBG, EUC,LFT Administer antibiotics (Do not wait for blood results) and resuscitate as indicated Complete physical examination, ongoing monitoring and escalate as necessary Inform as per Local CERS and primary oncologist Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

10. Algorithm: Assessment Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

11. Algorithm: Treatment Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

12. Antibiotic administration Gentamicin: 7.5 mg/kg/dose IV 24 hourly (max. dose 320 mg). Dose based on lean body weight for obese patients. Administer over 5 minutes. Ensure that line is flushed with 10-20 mls following Gentamicin and prior to any further doses of antibiotics. Piperacillin+Tazobactam: 100 mg/kg/dose IV 6 hourly (max. dose 4g Piperacillin component). Dose based on actual body weight. Administer over 20- 30 mins. Vancomycin: 15mg/kg/dose IV 6 hourly (max. dose 750mg). Dose based on actual body weight. Administer over at least 60 mins. If patient has previously experienced ‘red man syndrome’ administer over 2 hours. ^ Indications for Vancomycin: Obviously infected vascular devices (erythema/tenderness along subcutaneous track or purulent exit site discharge), MRSA carriers with clinical instability, High dose Cytarabine (>2gm/m 2 /day) recipients with clinical instability # Patients with Penicillin Allergy: Refer to table 1 in the guideline for first antibiotic choice Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

13. Antibiotic Administration For clinically stable patients the decision to continue Gentamicin beyond the first dose must be made after discussing with treating oncologist. Subsequent antibiotic choice/dose (i.e. after first dose) may need modification based on patient’s renal function, clinical stability and history of colonisation with multi-drug resistant organisms. These decisions must be made after discussing with treating oncologist. For patients continuing Gentamicin, drug level must be monitored just prior to second dose. For patients continuing Vancomycin, drug level must be monitored just prior to 5th dose. Some patients may require different initial antibiotics due to allergy or known history of colonisation with multidrug resistant organisms. It is very important that a clear documented plan is available and communication occurs between tertiary care hospital and local health care facility, as part of discharge planning, to ensure availability of these antibiotics at the local health care facility. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

14. Supportive Care interventions Analgesia and antipyretic medications as indicated (Do not administer rectally) Perform observations at a minimum of hourly or more frequently to identify deterioration of condition Commence strict fluid balance to monitor patient’s fluid status Assess the effectiveness of nursing interventions and general patient comfort Communicate laboratory results to medical staff as soon as they are available Discuss with the patient and parents the reason for the tests and procedures as well as the ongoing treatment plan Inform the patient’s treating team, when appropriate, of the patient’s condition. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients

15. Summary Infection in paediatric oncology/SCT patients is a Medical Emergency Most patients will present with fever BUT some may present without fever or with hypothermia Immunocompromised/Neutropenic patients may not have typical signs of infection or inflammation Prompt administration of antibiotics (Within 60 minutes of presentation) is the key to reduce morbidity and mortality Administration of antibiotics must not de delayed while waiting for blood results or to discuss the case with primary oncologist. Initial Management of fever or suspected infection in peaediatric oncology and stem cell transplantation patients