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.