Management of Fever in Pediatric Oncology and BMT Patients

Modified Date: 
July 24, 2019

PURPOSE/SCOPE: To provide standardized guidelines for management of fever in patients on the Pediatric Hematology/Oncology (Oncology) and Pediatric Blood and Marrow Transplant (BMT) services. For these guidelines, “BMT patient” refers to any patient on the BMT service who is undergoing or has undergone any form of hematopoietic stem cell transplantation (e.g. peripheral blood stem cell transplant, umbilical cord blood transplant, bone marrow transplant). These guidelines do not address all aspects of infection management in Oncology and BMT patients. Refer to Oncology and BMT Standards of Practice for supportive care practices not addressed in these guidelines.

SUMMARY: Patients who develop fever while undergoing cancer therapy or hematopoietic stem cell transplantation on the Pediatric Oncology or BMT services will be treated according to the best available clinical evidence and guidelines. Clinical algorithms for management of fever were developed based on national and international evidence-based guidelines, other published evidence, and local antimicrobial susceptibility data. 


Pediatric Oncology and BMT Patients with Fever: Emergency Department Management

Pediatric Oncology and BMT Patients with Fever: Initial Inpatient Management

Pediatric Oncology and BMT Patients with Fever: Inpatient Re-assessment

Inpatient Management of Clinically Stable Patients with Non-Neutropenic Fever

Antimicrobial Dosing Table


For patients with documented beta-lactam allergy:

  • Assessment via the Inpatient Beta-Lactam Allergy Guideline is strongly encouraged early in the course of treatment.
  • The guideline provides recommendations to assess prior reaction history, determine what antibiotic(s) can be given at full dose and/or test dose, and pathways for penicillin skin testing and beta-lactam test dose procedure.
  • A beta-lactam based regimen is considered optimal if it can be given. Alternatives that can be given at full dose are provided here, but are not preferred therapy based on spectrum of activity and/or toxicity profile.   

BACKGROUND: Pediatric oncology and BMT patients are at high risk for infection and related complications. Management goals include: 

1. Prompt initiation of broad-spectrum antibiotics (within 1 hour) for neutropenic patients and clinically unstable non-neutropenic patients. 

2. Identification and appropriate treatment of serious infections. 

3. Avoidance of antimicrobial resistance, superinfection, and other adverse effects of antimicrobial therapy. 

SUPPORTING EVIDENCE: Sources considered in development of the guidelines include references below and bloodstream infection antibiogram data from 2016-2018 evaluated for the Pediatric Oncology and BMT services. Proposed changes and supporting evidence were presented to the Pediatric Oncology, BMT and ID services. Presentation materials are available upon request from the Pediatric ASP. The updated guideline has been reviewed by all key collaborators and their additional recommendations incorporated. 

DEVELOPMENT AND REVIEW: Adapted from prior service-specific guidelines 01/2016 (ED algorithm); 03/2016 (inpatient algorithm); revision 07/24/19. Content developed by Pediatric Antimicrobial Stewardship Program in collaboration with Pediatric Oncology and Pediatric BMT services. Approved by UCSF Committee on Pharmacy and Therapeutics. Please direct questions about guideline content to [email protected] 


1. Lehrnbecher T, Robinson P, Fisher B, et al. Guideline for the management of fever and neutropenia in children with cancer and hematopoietic stem-cell transplantation recipients: 2017 update. J Clin Oncol 2017;35:2082-2094. 

2. Averbuch D, Orasch C, Cordonnier C, et al. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia. Haematologica 2013; 98:1826-1835. 

3. Levinson A, Pinkney K, Jin Z, et al. Acute gastrointestinal graft-vs-host disease is associated with increased enteric bacterial bloodstream infection density in pediatric hematopoietic stem cell transplant recipients. 2015; 61:350-357. 

4. Satwani P, Freedman JL, Chaudhury S, et al. A multicenter study of bacterial blood stream infections in pediatric allogeneic hematopoietic cell transplantation recipients: the role of acute gastrointestinal graft-versus-host-disease. Biol Blood Marrow Transplant 2017;23:642-647. 

5. Horn B, O'Kane S, Wattier RL, et al. Risk of serious bloodstream infections is low in pediatric hematopoietic stem cell transplant (HSCT) recipients with fevers due to antithymocyte globulins and alemtuzumab. Bone Marrow Transpalnt 2016;51.