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Febrile Neutropenia

Neutropenia (febrile); High risk.

Possible Therapeutic Options

Comments

Temp greater than 38°C(100.4°F) and ANC <500 cells/mm3.

Common Pathogens

Bacteria: 
[1] aerobic Gram-negative bacilli  (enterobacteraciae, pseudomonas); also consider other resistant GNB.  
[2]   aerobic Gram-positive cocci (staphylococci): e.g. S. aureus including MRSA and coagulase negative Staphylococci.  Streptococci;  Enterococcus spp; others.

Fungi:
Candida, aspergillus, fusarium, others.

Initial therapy:
[Detailed clinical history should be obtained. Review possible risk factors such as malignancy, comorbidities, presence of indwelling catheters, etc.  Adjust therapy based on patient response.   Therapy should be guided by susceptibility testing, drug allergies, and recent antibiotic therapy. ]  

   Cefepime 2 grams IV every 8-12 hours OR Piperacillin-tazobactam (Zosyn ®)  3.375 to 4.5  grams IV q6h  OR Ceftazidime 2 grams IVPB q8h  OR Imipenem 500mg IV every 6 hours [Range: 250-1000 mg q6-8h]   OR Meropenem 0.5 - 1 gram IV q8h  (life-threatening infection -unlabeled use: 2 grams IV q8h) May consider combination therapy by adding one of the following (synergy may improve response and reduce risk of resistance): Gentamicin 2mg/kg IV q8-12h or consider high-dose extended-interval dosing:  5 to 7 mg/kg q24-48h.  Adjust regimen based on estimated clearance  OR Tobramycin 2 mg/kg IV q8-12h or consider high-dose extended-interval dosing:  5 to 7 mg/kg q24-48h.  Adjust regimen based on estimated clearance OR Amikacin 5 to 7.5 mg/kg IV q8h or consider high-dose extended-interval dosing: 15 mg/kg q24-48h.  Adjust regimen based on estimated clearance OR Ciprofloxacin  400mg IV q8h

Additional agents may be required based on the patient's condition/response (complicating factors; secondary infections; inadequate response to therapy; presence of resistant organisms such as MRSA, VRE, GNB-ESBLs) :

Vancomycin - (patient-specific regimen - trough goal 15-20 mcg/ml) Linezolid 600 mg orally or IV q12h Daptomycin 6 mg/kg IV once daily.    - NOT FOR PNEUMONIA Antifungal:
Anidulafungin OR Caspofungin OR  Liposomal Amphotericin-B OR Micafungin OR Voriconazole.  

Neutropenia (febrile), High risk.