Choice of empirical therapy for patients with febrile neutropenia
Detailed advice on the choice of antimicrobial regimen for febrile neutropenia is included in the Australian consensus guidelines1.
When possible, the choice of antimicrobials for treatment of febrile neutropenia should be based on local protocols, or clinical microbiology or infectious diseases advice. Empirical antibiotic regimens based on local epidemiology can improve outcomes because survival is increased when appropriate antibiotics are given early; this is particularly important for patients with sepsis, septic shock or requiring intensive care support.
If the patient has been screened for faecal carriage of multidrug-resistant Gram-negative bacteria, treatment should be guided by the results of susceptibility testing.
In the absence of local protocols and immediately available clinical microbiology or infectious diseases advice, the empirical regimens in this topic can be used; however, seek advice and modify therapy as soon possible.
The empirical regimens in this topic include activity against Pseudomonas aeruginosa, which (although a pathogen in only a minority of cases) is associated with high rates of morbidity and mortality. Meta-analyses show that the antipseudomonal drugs piperacillin+tazobactam, cefepime and ceftazidime are suitable for empirical therapy in the majority of patients.
However, if the patient is colonised, or has recently been infected, with a multidrug-resistant Gram-negative bacterium, use the empirical regimens with activity against multidrug-resistant Gram-negative bacteria. These regimens are not indicated on the basis of other risk factors for resistant infection.
Despite Gram-positive bacteria being the most common cause of febrile neutropenia, vancomycin is not routinely recommended in these guidelines because controlled trials have not demonstrated a significant benefit from its inclusion in the empirical regimen.
Early antifungal therapy may be required for patients suspected to have fungal infection, including unstable patients at high risk of fungal infection. The choice of treatment depends on the prophylactic antifungal regimen used—seek expert advice.
Modify therapy as soon as additional information is available (eg source of infection; results of Gram stain, culture or susceptibility testing; expert advice). Evaluate appropriateness of antimicrobial therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.
Data to inform the appropriate duration of therapy are limited. The duration is influenced by the response to antimicrobial therapy, isolation of a pathogen and the rate of neutrophil recovery—seek expert advice2.
Trial data indicate that a subgroup of low-risk patients with febrile neutropenia can complete treatment at home with oral therapy—seek expert advice and refer to the Australian consensus guidelines13.