A 36-year-old man with history of acute myelogenous leukemia is admitted to the ICU with neutropenic fever and low blood pressure that requires norepinephrine drip. The patient finished his first cycle of chemotherapy 10 days ago. He denies respiratory, gastrointestinal, or urinary symptoms. CBC reveals mild thrombocytopenia and an absolute neutrophil count of 100/µL. Urinalysis is within normal limits and chest x-ray does not show any infiltrate. Awaiting culture results, which of the following antibiotic regimens is most appropriate?A) Imipenem
Neutropenic fever is a medical emergency. Infections, most commonly gram-negative bacteria such as P aeruginosa, are responsible for most cases. Prompt empiric antibiotic therapy with two antibiotics from two different antibiotic classes (double coverage) that have anti-pseudomonal activity is most appropriate. Adding an antibiotic with anti–methicillin-resistant Staphylococcus aureus (MRSA) activity to the initial antibiotic regimen is indicated if the patient was on antibiotic prophylaxis before the onset of the neutropenic fever or if he has any of the following conditions: skin infection, moderate to severe mucositis, central venous catheter, or shock (as in this vignette). Imipenem alone is not enough because it lacks anti-MRSA activity. Vancomycin does not provide gram-negative coverage and should never be used alone in the treatment of neutropenic fever. Awaiting culture results without initiating empirical antibiotic coverage is inappropriate because it increases the patient’s mortality risk. Antifungal therapy is often added in the subsequent days if the patient fails to respond to broad-spectrum antibiotics.