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• Minimum 2 weeks
Bacteraemia, deep tissue infection
After 2 weeks if remains neutropenic (< 500/mm3), BUT afebrile,
no disease focus, mucous membranes, skin intact, no catheter site
infection, no invasive procedures or ablative therapy
planned…cease antibiotics and observe
When temperatures do not go away…
Non-bacterial infection (eg fungal, viral)
Bacterial resistance to first line therapy (MRSA, VRE)
Slow response to drug in use
Superinfection
Inadequate dose
Drug fever
Cell wall deficient bacteria (eg Mycoplasma, Chlamydia)
Infection at an avascular site (abscess or catheter)
Disease-related fever
Antifungals
• Easy to Initiate/ Difficult to stop
• Aggressive search for Fungal Infections
• Pulmonary Aspergillosis/Sinusitis / Hepatic Candidiasis
ANTI FUNGALS
• AMPHO B IV (1.5 mg/kg/day) drug of choice for
high risk patients
Alternative options
• FLUCONAZOLE (10 mg/kg/day)
• ITRACONAZOLE (3-5 mg/kg)
• ECHINOCANDINS
• Voriconazole is NOT FDA approved for empiric
therapy for persistent fevers in FN
Fluconazole ~ candida
DO NOT Use
• Fluconazole acceptable if NO Fluconazole if:
Moulds and Resistant Candida • Evidence of Sinusitis
( C. Krusei and C. glabrata ) or
Uncommon. • Radiographic
evidence of Evidence
of Pulmonary disease
Low risk patients
• If patient has received
Fluconazole
prophylaxis before.
Antibiotic Prophylaxis for Afebrile
Neutropenic Patients
• Use of antibiotic prophylaxis is not routine because of emerging antibiotic
resistance **, except for
• Trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonitis.
• Antifungal prophylaxis with fluconazole
• Antiviral prophylaxis with acyclovir or ganciclovir are warranted for patients
undergoing allogenic hematopoietic stem cell transplantation.
** CID 40:1087&1094,2005
NEJM 353:977,988&1052,2005
Use of Antiviral Drugs