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Oncology - care of the oncology patient admitted to PICU with persistent fever

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Febrile at 48 hours

If negative cultures, reassess and re-culture and add Vancomycin 15mg/kg Q6H according to levels:

  • Maximum dose is 750mg Q6H
  • Higher doses may be used in certain cases.
  • If negative cultures for gram +ve organisms, stop Vancomycin after 48 hrs

Febrile at 4-5 days

  • Reassess and consider more invasive investigative procedures and imaging
  • Consult ID team
  • Consider switching to Meropenem IV 20mg/kg (max1g) Q8H
  • Add Liposomal Amphotericin (AmBisome) IV 3mg/kg once daily
    • Ambisome can be commenced before 4-5 days at the discretion of the Oncology Consultant regardless of fever status for children who are neutropenic, on steroids and with a prior history of prolonged antibiotics
    • Conventional Amphotericin B is not recommended for reasons of toxicity in this patient population
  • Close monitoring of electrolytes and renal function is essential daily

Monitoring levels

Amikacin:

  • Trough levels required, take level prior to second dose and every 3 to 5 days if normal renal function.
  • Aim for trough less than 1mg/L.
    • If impairment of renal function or other nephrotoxic agents being administered take levels more frequently
    • If trough levels high may need to space out dosage interval
  • Peaks not required for once daily dosing

Vancomycin:

  • Take trough level immediately prior to fourth dose and every 3 to 5 days if normal renal function and vancomycin levels within range
  • Aim for trough: 10mg-15mg/L, up to 20mg/L in certain cases
  • Peaks not required

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Document Control

  • Date last published: 10 June 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Fiona Miles
  • Editor: John Beca
  • Review frequency: 2 years