A 67 year old man who is currently on chemotherapy treatment for a malignancy suddenly develops febrile neutropenia. He has been commenced on tazocin and gentamicin. He has recently commenced meropenem but his fever still remains at 39°C on the 3rd day. Two blood tests and urine cultures have come back negative. Investigation done this morning show:
Haemoglobin 104 g/L White cell count 0.5 x 109/L Platelets 35 x 109/L
What is the SINGLE best management?
A. Continue IV antibiotics and add oral antifungals
B. Continue IV antibiotics and add IV antifungals
C. Stop antibiotics
D. Continue present antibiotics
E. Repeat blood culture
Continue inpatient empiric antibiotic therapy in all patients who have unresponsive fever unless an alternative cause of fever is likely. It is quite the norm to add on IV antifungals for neutropenic sepsis as well.
If there was an option to order investigations for fungal infections in this question, that would be correct as well.
General Management for Neutropenic Sepsis
• antibiotics must be started immediately (do not wait for the WBC) • NICE recommend starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately • if patient is still febrile and unwell after 48 hours → an alternative antibiotic such as meropenem is often prescribed +/- vancomycin • if patient is not responding after 4-6 days → order investigations for fungal infections, rather than just starting antifungal therapy blindly