17.1 Sepsis

CPHON Test Content Outline (TCO) V.A.1 tests sepsis as an oncologic emergency. Fever and neutropenia (FN) is the pediatric picture you must not miss. This is not the Domain IV lecture on nadirs and Pneumocystis prophylaxis, not the colony-stimulating-factor supportive-care section, and not a demand that you recite a single adult Surviving Sepsis Campaign minute-number as Oncology Nursing Certification Corporation (ONCC) fact. The goal is immediate evaluation and rapid empiric antibiotics. The CPHON product is a nurse who recognizes FN and shock, takes first actions that do not wait for a 0.1°C argument, and monitors perfusion, skin, and the central line until the child is stable or in intensive care.

A 4-year-old on acute lymphoblastic leukemia (ALL) induction whose parent calls at 02:00 with a temperature of 38.2°C, a 12-year-old with acute myeloid leukemia (AML) and a black necrotic patch on the thigh, and a toddler with a port who is just sleepy are the same emergency at different ages.

Fever, neutropenia, and why 0.1°C is not the debate

Fever in pediatric oncology is protocol- and institution-specific. Many Children's Oncology Group (COG) pathways and Association of Pediatric Hematology/Oncology Nurses (APHON) teaching materials treat a single oral or equivalent temperature of ≥38.3°C (101.0°F) or a temperature of 38.0°C (100.4°F) sustained over a defined window as fever. Use the treating protocol and institution definition. Do not delay the workup or the first antibiotic while the team argues whether 38.2°C counts. A mottled, poorly filling, or hypotensive child is septic until proven otherwise even at 37.9°C.

Neutropenia that lands the child in a high-risk FN window is typically an absolute neutrophil count (ANC) <500/µL, or <1,000/µL and falling. ANC equals (percent segmented neutrophils plus percent bands) times white-cell count, divided by 100. Profound neutropenia (often ANC <100/µL) and prolonged neutropenia—AML induction, relapsed disease, hematopoietic stem cell transplant (HSCT) conditioning—raise the risk of rapid gram-negative death and, later, fungal infection. Last week's clinic ANC of 1,200/µL does not clear a child who is mid-nadir tonight.

FN is a medical emergency. Do not discharge a febrile neutropenic child from triage to see if acetaminophen brings it down. Do not teach a parent to give acetaminophen at home and wait. Antipyretics mask the next reading and spend the hour bacteria use to multiply. Teaching is: use the thermometer the team issued, call the oncology number the same hour the definition is met, and come in—night, weekend, or the child looks fine.

Walk the 02:00 call. The 4-year-old on ALL induction has a single oral temperature of 38.2°C and is watching a tablet. The protocol's printed fever card says ≥38.3°C once or 38.0°C sustained. The parent asks whether to give acetaminophen and recheck at breakfast. The answer is come in now. Do not bargain about a tenth of a degree. On arrival, obtain a complete blood count with differential. If the ANC is 400/µL—or is 800/µL and falling through induction—this is FN. If the count is not back yet and the child is poorly perfused, treat as FN. Time spent debating the thermometer is time the first beta-lactam is not infusing.

First actions: cultures that do not delay the beta-lactam

The first-hour cluster is assessment plus source work that does not delay drugs:

• Airway, breathing, circulation, mental status, capillary refill, pulses, and blood pressure. Hypotension is a late pediatric shock sign. Tachycardia, delayed refill, cool extremities, and a change in play or irritability come first. An infant who will not feed and an adolescent who is suddenly quiet are perfusion clues, not personality.
• Blood cultures from every central-line lumen plus a peripheral culture per policy, drawn before antibiotics if that does not delay the first dose. If the peripheral stick is hard, give the antibiotic. Do not wait 40 minutes for a second attempt.
• Directed cultures (urine, stool, respiratory, wound; cerebrospinal fluid only if meningitis is in play and the child can safely be positioned) never replace blood cultures.
• Lactate, complete blood count with differential, chemistry, and coagulation studies as ordered.
• Prompt empiric antipseudomonal beta-lactam: cefepime, piperacillin-tazobactam, or meropenem as the protocol lists. Pseudomonas aeruginosa and other gram-negatives historically kill quickly in FN; that is why the first drug covers them. A gram-positive-only agent is not monotherapy.
• Add vancomycin when team indications are met: hemodynamic instability, suspected central-line infection, severe mucositis, or known methicillin-resistant Staphylococcus aureus. Vancomycin is not automatic for every fever.
• Isotonic fluid resuscitation for shock, then intensive care if perfusion does not restore. Watch overload in a recently transfused child or one with a mediastinal mass (signpost the cardiopulmonary-emergency chapter).

Many pediatric centers track time-to-antibiotic as a quality metric. That is local process, not a number ONCC publishes on the CPHON outline. Do not memorize a single Surviving Sepsis minute figure as exam fact. Frame every item as immediate evaluation and rapid empiric antibiotics.

Reassess after the first fluid bolus and the first antibiotic. Capillary refill that stays delayed, lactate that rises, or a child who was playing and now cannot sit up is failing outpatient-style observation. Call a rapid response or intensive-care transfer. Colony-stimulating factors may shorten neutropenia on selected protocols; they do not treat septic shock and belong in the supportive-care chapter, not as the sepsis rescue.

Central-line infection, ecthyma gangrenosum, viruses, and fungi

A central venous catheter—port, tunneled line, or peripherally inserted central catheter—is both lifeline and infection risk. Fever without another source in a child with a line is catheter-related bloodstream infection until cultures say otherwise. Culture every lumen. Do not pull the line at the first fever; removal is a team decision for tunnel infection, persistent bacteremia, Candida in the line, or instability that does not respond. Site erythema, drainage, and tunnel pain are not tape irritation.

Ecthyma gangrenosum is a necrotic, punched-out skin lesion with an erythematous halo, classically from Pseudomonas bacteremia during neutropenia. A black eschar on a neutropenic child's thigh or perineum is not a bruise from a platelet count of 12,000/µL. Photograph, culture as ordered, notify immediately, and keep antipseudomonal coverage in place. Do not wait for a weekday dermatology clinic. New lesions appearing while you watch are a shock warning, not a coincidental rash.

Viral and fungal pathogens rise when neutropenia is prolonged. Respiratory viruses, herpes simplex, and varicella-zoster need isolation and directed therapy as ordered. Candida and Aspergillus enter when fever persists after broad antibacterial coverage, especially in AML and HSCT. Do not invent a single start-amphotericin-on-hour-96 ONCC rule. Teach that persistent fever in prolonged neutropenia triggers imaging, biomarkers the team uses, and empiric or preemptive antifungal therapy per protocol. Breakthrough Pneumocystis is a missed trimethoprim-sulfamethoxazole story from the immunologic-effects chapter.

Monitoring after the first dose is serial: vital signs, perfusion, urine output, lactate trend, mental status, and a full skin and line-site exam every shift. A child who looked well at 09:00 and is mottled at 11:00 is failing. Family teaching closes the loop: a working thermometer, the protocol fever number on the refrigerator, no acetaminophen-and-wait, and a 02:00 driver plan.

The CPHON product is a culture set that did not delay the beta-lactam, a parent who did not dose acetaminophen overnight, a black skin lesion named as ecthyma, and a child whose perfusion is watched until it is normal.