Suggested initial parenteral antimicrobial therapy for children hospitalized with non-chemotherapy-induced neutropenia and fever

Clinical features	Suggested parenteral antibiotic(s)
Uncomplicated fever episode	One of the following: Cefepime Meropenem Piperacillin-tazobactam
Signs of sepsis	Consultation with an expert in pediatric critical care and infectious diseases is suggested
Abdominal pain, rectal pain, perineal inflammation, or blood per rectum	One of the following: Combination cefepime and metronidazole Meropenem Piperacillin-tazobactam
Suspected Clostridioides difficile	Refer to UpToDate content on treatment of C. difficile in children
Radiographically documented pneumonia	Combination therapy with: Cefepime or meropenem or piperacillin-tazobactam, and Vancomycin* if MRSA suspected
Evidence of meningitis or new-onset neurologic signs	Combination therapy with: Cefepime or meropenem, plus Vancomycin
Clinically suspected CVC infection	Combination therapy with: Cefepime or meropenem or piperacillin-tazobactam, plus Vancomycin*^¶
Skin or soft tissue infection	Combination therapy with cefepime plus either clindamycin (if the prevalence of clindamycin-resistant Staphylococcus aureus in the community is acceptably low) or vancomycin^Δ, or Combination* therapy with meropenem or piperacillin-tazobactam plus vancomycin*^Δ
Known colonization with MRSA or penicillin- and cephalosporin-resistant Streptococcus pneumoniae
High prevalence of MRSA infections in the community

This table is meant for use with UpToDate content on non-chemotherapy-induced neutropenia in children. Refer to UpToDate content for additional details (eg, risk categorization, doses, modification of empiric therapy, duration of antimicrobial therapy). The initial empiric regimen is individualized (eg, for drug allergies, organ dysfunction, use of prophylactic antimicrobial agents).

MRSA: methicillin-resistant S. aureus; CVC: central venous catheter.

* The combination of vancomycin and piperacillin-tazobactam is associated with increased risk of acute kidney injury and should be avoided.

¶ Ceftaroline and daptomycin are alternatives but are not used routinely.

Δ Linezolid is an alternative for children known to be colonized with, or previously infected with, vancomycin-resistant gram-positive organisms but should be used with caution because it has been associated with neutropenia.

References:

Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:e56.
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.

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Suggested initial parenteral antimicrobial therapy for children hospitalized with non-chemotherapy-induced neutropenia and fever