No focus

Low risk patients:

• clinically stable
• no comorbidities
• neutropenia expected to be < 7 days

may not require such broad spectrum antibiotic therapy. Refer to local guidelines.

High risk patients:

• 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.