High risk

  • Profound neutropenia (ANC < 0.1 x 109/L) anticipated to be > 7 days
  • Significant comorbid conditions, including:
    • hemodynamic instability
    • oral or GI mucositis that impairs swallowing or causes severe diarrhea
    • new onset abdominal pain, nausea or vomiting, or diarrhea
    • neurologic changes/confusion
    • intravascular catheter infection
    • pneumonia/hypoxemia/chronic lung disease
    • hepatic insufficiency (AST > 5x normal value)
    • renal insufficiency (Clcr < 30mL/min).

- Median time to defervescence for high risk patients treated with appropriate empiric antibiotic therapy is 5 days.

- Antifungal therapy: using agent from a different class from that used for prophylaxis should be considered in patients who remain febrile and neutropenic at day 4-7 despite adequate antibiotic coverage.

  • Infectious Diseases consult recommended.
  • Repeat blood cultures plus ultrasound of abdomen recommended.
    or
  • If high risk for mould infections (hematologic malignancy, especially AML), repeat blood cultures including fungal blood cultures and CT chest/abdomen/sinuses.

- Consider switch to oral therapy if:

  • non-septic presentation (no chills, hypotension or fluid resuscitation)
  • patient stable
  • mucositis resolving
  • neutrophils > 0.1x109/L.
  • adequate GI absorption.
Usual Pathogens
Gram positive:

Coagulase negative Staph
Enterococcus spp
Viridans Group Strep
S. aureus/MRSA
S. lugdunensis
Corynebacterium spp
Bacillus cereus
Rothia spp
ß-haemolytic Streptococci
S. pneumoniae
Rhodococcus spp
Abiotrophia spp
Granulicatella spp
Leuconostoc spp
Pediococcus spp

 
Gram negative:

Enterobacterales
Pseudomonas spp
Stenotrophomonas maltophilia
Achromobacter spp
Acinetobacter spp
Burkholderia spp
Capnocytophaga spp
Eikenella spp

 

Anaerobes
Polymicrobial (20-30%)
Fungi (< 5%)
Viruses

Hemodynamically Stable

Empiric Therapy Dose Duration
Piperacillin-tazobactam 4.5g IV q6-8h See Duration

Alternative

Empiric Therapy Dose Duration
Cefepime 2g IV q8h See Duration
or    
Imipenem 500mg IV q6h See Duration
or    
Meropenem 500mg IV q6h or 1g IV q8h See Duration

Severe ß-lactam allergy/anaphylaxis

Empiric Therapy Dose Duration
Vancomycin 15mg/kg IV q12h See Duration
+    
Ciprofloxacin 400mg IV q8-12h/750mg PO bid  
+/-    
Metronidazole 500mg IV/PO q12h  
+/-    
[Gentamicin 7mg/kg IV daily  
or    
Tobramycin] 7mg/kg IV daily  

Hemodynamically unstable

Empiric Therapy Dose Duration
Piperacillin-tazobactam 4.5g IV q6-8h See Duration
+    
Vancomycin 15mg/kg IV q12h  
+    
[Gentamicin 7mg/kg IV daily  
or    
Tobramycin] 7mg/kg IV daily  

Severe ß-lactam allergy/anaphylaxis

Empiric Therapy Dose Duration
Vancomycin 15mg/kg IV q12h See Duration
+    
Ciprofloxacin 400mg IV q8-12h/750mg PO bid  
+    
Metronidazole 500mg IV q12h  
+    
[Gentamicin 7mg/kg IV daily  
or    
Tobramycin] 7mg/kg IV daily