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.

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

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

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

Hemodynamically Stable

Alternative

Severe ß-lactam allergy/anaphylaxis

Hemodynamically unstable

Severe ß-lactam allergy/anaphylaxis