2. When to Narrow or Discontinue Coverage a. NO organism found If no source for is found, continue cefepime monotherapy until all below are satisfied: If afebrile at least 48 hours clinically well (i.e. discharge-ready) with ANC and actively rising ≥200 a source for the fever is identified and the patient shows clinical improvement/resolution of If symptoms, continue appropriate therapy for the identified source. This continue as after discharge, if needed, for a total course oral antibiotics (including the inpatient therapy) of 14 days total at minimum, with total duration and antibiotic choice depending on the source. May call ID for guidance on oral transition vancomycin was added empirically If cultures are negative, and there is no clinical indication for continued use, would If consider stopping vancomycin after 48 hours. Clinical indications for continued use would include improvement in clinical status with initiation of vancomycin, or indications for initial use as on page 1. double gram-negative coverage was added empirically If It may be more difficult to narrow coverage given the patient’s prior instability. Narrowing should be considered on a case-by-case basis, depending on the reason for adding the drug. May call ID for guidance b. an organism is found If Gram-Negative Infections stop vancomycin if it was empirically and patient is clinically stable narrow based on sensitivities but no narrower than cefepime monotherapy. can stop double coverage if patient afebrile and clinically stable for at least 48 hours Gram-Positive Infections required by sensitivities, add Vancomycin If there is good evidence for GPCs as the source of fever (see above and on page 1) and If the patient is now clinically well and afebrile x 48 hours, could consider discontinuing cefepime and continuing on vancomycin monotherapy or narrower GPC coverage if appropriate. the organism is sensitive to oxacillin or ampicillin or 1st-generation cephalosporins, If can continue to use cefepime monotherapy. a more resistant GNR or GPC is If strongly consider an ID consult treatment decision should still be guided by susceptibility panel and potential toxicity. 3. When to Escalate to Antifungal Coverage
2. When to Narrow or Discontinue Coverage a. If NO organism found If no source for is found, continue cefepime monotherapy until all below are satisfied: afebrile at least 48 hours clinically well (i.e. discharge-ready) with ANC ≥200 and actively rising If a source for the fever is identified and the patient shows clinical improvement/resolution of symptoms, continue appropriate therapy for the identified source. This continue as oral antibiotics after discharge, if needed, for a total course (including the inpatient therapy) of 14 days total at minimum, with total duration and antibiotic choice depending on the source. May call ID for guidance on oral transition If vancomycin was added empirically If cultures are negative, and there is no clinical indication for continued use, would consider stopping vancomycin after 48 hours. Clinical indications for continued use would include improvement in clinical status with initiation of vancomycin, or indications for initial use as on page 1. If double gram-negative coverage was added empirically It may be more difficult to narrow coverage given the patient’s prior instability. Narrowing should be considered on a case-by-case basis, depending on the reason for adding the drug. May call ID for guidance b. If an organism is found Gram-Negative Infections stop vancomycin if it was empirically and patient is clinically stable narrow based on sensitivities but no narrower than cefepime monotherapy. can stop double coverage if patient afebrile and clinically stable for at least 48 hours Gram-Positive Infections If required by sensitivities, add Vancomycin If there is good evidence for GPCs as the source of fever (see above and on page 1) and the patient is now clinically well and afebrile x 48 hours, could consider discontinuing cefepime and continuing on vancomycin monotherapy or narrower GPC coverage if appropriate. If the organism is sensitive to oxacillin or ampicillin or 1st-generation cephalosporins, can continue to use cefepime monotherapy. If a more resistant GNR or GPC is strongly consider an ID consult treatment decision should still be guided by susceptibility panel and potential toxicity. 3. When to Escalate to Antifungal Coverage
Neutropenic%20Fever%20Empiric%20Coverage%20FINAL.docx