Duration and modification of empirical antibiotics

Antibiotics may be discontinued after 3 to 5 afebrile days provided that the patient is very carefully observed. Some clinicians prefer to continue antibiotics until the neutrophil count rises above 0.5 * 109/l, but this is associated with an increase in fungal infections, emergence of resistant bacteria, and an increased risk of antibiotic-related toxicity. In patients with persistent culture-negative fever 72 h after the commencement of empirical antimicrobial therapy, re-evaluation including a full medical examination, repeated cultures, and chest radiography should be performed. Metronidazole should be added in cases of severe mucositis, necrotizing gingivitis, perianal tenderness, and acute abdominal pain. However, in the absence of any clues to the etiology of persistent fever, antifungal treatment should be commenced (Fig 1).

Fig. 1 Empirical approach in febrile neutropenic patients.

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