Initial empirical antimicrobial therapy: duration and subsequent modifications

Abstract

Neutropenic patients at low risk of complications can receive oral ciprofloxacin or levofloxacin as outpatients. These agents plus amoxicillin/clavulanate or other penicillins, cephalosporins, or penem compounds are indicated to treat infections with gram-positive organisms in patients with oral mucositis or skin lesions. Parenteral fourth-generation cephalosporins or carbapenems can be given. For high-risk patients, monotherapy with cefepime or the carbapenems can be used. Methicillin-resistant Staphylococcus aureus should be treated with vancomycin or teicoplanin. For combination therapy, a third- or fourth-generation cephalosporin or carbapenem plus an aminoglycoside is desirable. Defervescence in 3-5 days for at least 7 days is suggested for subsequent management. Initial antibiotic(s) can be continued for patients who remain in good condition. For persistent fever after 3-5 days, the patient should be thoroughly reassessed. An aminoglycoside should be added for those initially treated with monotherapy. The initial cephalosporin can be changed to another cephalosporin or a carbapenem, or the initial carbapenem can be changed to a broad-spectrum cephalosporin. For patients initially receiving dual therapy, the cephalosporin or carbapenem can be changed as with monotherapy, whereas the initial aminoglycoside should be changed to another aminoglycoside or intravenous ciprofloxacin.